Documentos de Académico
Documentos de Profesional
Documentos de Cultura
HARTLAND'S
Michael Heap
Kottiyattil IC Aravind
Foreword by
Peter B. Bloom
www.harcourtinternational.com
Bringing you products from all Harcourt Health Sciences companies
including Baillire Tindall, Churchill Livingstone, Mosby and W.B.
Saunders
Browse for latest information on new books, journals and
electronic products
Search for information on over 20,000 published titles with full
product information including tables of contents and sample
chapters
keep up to date with our extensive publishing programme in
your field by registering postal updates
Secure online ordering with prompt delivery, as well as full
contact details to order by phone, fax or post
News of special features and promotions
If you are based in the following countries, please visit the countryspecific site
to receive full details of product availability and local ordering information
USA: www.harcourthealth.com
Canada: www.harcourtcanada.com
Australia: www.harcourt.com.au
Baillire Tindall Churchill Livingstone Mosby W.B. SAUNDERS
JOHN HARTLAND (1901-1977)
Most of the tributes to John Hartland on his death in 1977 bore witness to
his personal qualities - warmth, energy and enthusiasms, ranging from
classical music, photography, football, the detective novel to the wines of
France - before describing his contribution in establishing the credentials
of hypnotherapy as a branch of psychosomatic medicine and in rendering
it more accessible to general medical and dental practitioners. Indeed, his
personality had much to do with his own success as a therapist, together
with his extraordinary care for verbal suggestion techniques: he took
permanent delight in the richness and rhythms of the English language.
He thought later that he owed much to 30 years' experience in general
medicine practice in West Bromwich, in the heart of the 'Black Country'
of the English industrial Midlands, among a people for whom he felt
great affection.
His commitment to psychiatry came, however, from frustration at
being denied the opportunity to leave general medicine. This was in
1939 when at the outbreak of war he volunteered for the Royal Navy. He
was told to stay where he was. The industrial Midlands were likely to
be bombed. He turned his energies to the organization of an air raid post,
to the raising of morale and money for military charities through the
writing and production of musical revues, to the Red Cross, and - through
curiosity in the phenomena of hypnosis - to psychiatry.
After the war he combined full-time general medicine with a hospital
appointment as consultant psychiatrist and a growing private psychiatric
practice. He began to lecture and demonstrate, first in Britain, then in the
United States, France, Sweden, Australia and Singapore; was a driving
force in the British Society of Medical and Dental Hypnosis; and edited the
British Journal of Medical Hypnosis. The turning-point was the publication of
his paper on "ego-strengthening technique" in the United States in the
early 1960s. One of the greatest rewards of his travels to the United States
was his friendship with Milton Erickson.
Nothing would have given him greater satisfaction today than to know
that his book, which first appeared in 1966, is still valued and thought
worthy of a fourth edition.
Hartland's Medical and Dental Hypnosis
The late David Waxman, editor of the third edition
Founder and First President of the section for Medical and Dental
Hypnosis of the Royal Society of Medicine; Past President of the
European Society for Hypnosis in Psychotherapy and Psychosomatic
Medicine; Past President and Founder Fellow of the British Society of
Medical and Dental Hypnosis; Past Vice President of the British Society
of Experimental and Clinical Hypnosis; Past Affiliate of the Royal
College of Psychiatrists; Founder Fellow of the International Society of
Psychosomatic Obstetrics and Gynaecology; Formerly Associate
Specialist in Psychiatry, Central Middlesex Hospital, London.
For Churchill Livingstone:
Publishing Manager, Health Professions: Inta Ozols
Project Development Manager. Karen Gilmour
Project Manager: Alison Ashmore
Design Direction: George Ajayi
Contents
Extracts from the forewords to the second and third editions xi
Foreword to the fourth edition by Peter B. Bloom xiii
Preface xv
Acknowledgements xxi
SECTION 1 The history and nature of hypnosis
1. Overview of the history of hypnosis 3
2. The nature of hypnosis: suggestion and trance 15
3. Hypnotic susceptibility and its measurement 29
4. Theories of hypnosis 41
SECTION 2 Basic procedures in clinical hypnosis
5. Preparation for clinical hypnosis 61
6. Hypnotic induction and deepening procedures:
first approach 67
7. Hypnotic induction and deepening procedures:
second approach 83
8. Further ethical matters and precautions during the
preparation phase of hypnosis 97
9. Self-hypnosis 101
10. Variations in style: permissive, indirect and alert
approaches 107
11. Suggestion, posthypnotic suggestion and
ego-strengthening in therapy 121
12. Behavioural techniques for self-control 135
viii CONTENTS
13. Metaphor and story technique 143
14. Basic procedures with children 155
SECTION 3 The application of hypnotic procedures in
psychological therapy
15. Orientation to the psychotherapies and the concept of a
'working model' 173
16. Introduction to psychodynamic and humanistic approaches 183
17. Ericksonian approaches to psychotherapy 193
18. The unconscious mind and the repression of memories 201
19. Hypnotic procedures in psychodynamic therapy 217
20. Behaviour therapy: an introduction and the application of
hypnosis 255
21. Cognitive therapy: an introduction 271
22. An eclectic approach to psychotherapy augmented by
hypnosis 283
23. Risks, precautions and contraindications 287
SECTION 4 The application of hypnosis to specific medical,
dental and psychological problems
24. Hypnosis for smoking cessation, weight reduction and
insomnia 295
25. Hypnosis in the treatment of psychosomatic problems 323
26. Hypnosis and pain 347
27. Hypnosis and cancer 365
28. Hypnosis in obstetrics and gynaecology 379
29. Hypnosis in dentistry 397
30. Hypnosis for anxiety disorders 411
31. Hypnosis in the treatment of miscellaneous psychological
problems and disorders 435
32. Medical and psychological problems in children and
adolescents 457
CONTENTS ix
SECTION 5 The professional practice of hypnosis
33. Evidence for the benefits and the adverse effects of hypnosis 473
34. Issues in professional practice 491
Appendix I Clinical hypnosis and memory 501
Appendix II Ethical guidelines of the International
Society of Hypnosis 505
Index 509
Extracts from the forewords to the
second and third editions
SECOND EDITION
Each page makes clear that a long overlooked and seriously neglected need
is being fulfilled, one of great importance in the furtherance of the scientific
modality of hypnosis as an important adjunct in the healing arts. A
methodology of the medical use of hypnosis of great value to the patient
himself and to medicine as a whole is developed and adequately elucidated
in this book. This is achieved by centring around a clear-cut well-ordered
basic orientation which acquaints the medical practitioner with the varieties
of hypnotic understandings pertinent to the clinical practice of medicine.
Milton H. Erickson
THIRD EDITION
The practice of hypnotherapy is both an art and a science. As an art it is
often best communicated through an apprenticeship to an experienced
expert. However, such an opportunity is not always provided for students
in medical and dental study, and not easy for those already in practice who
wish to become familiar with hypnotherapy. For both student and qualified
practitioner this book is an attractive alternative because of the detail with
which appropriate practices are presented. ... the intention is to present
those in practice with what is positive that has been learned through successful
hypnotherapy with patients. Welfare of the patient is what therapy
is all about.
Ernest K. Hilgard
This work, which covers large areas of medicine and surgery, thus acquires
great importance not only on account of the numerous and varied references
to situations relieved by hypnosis, but also for the holistic vision permeating
it and consequently the quality of approach for the patient, that
important approach in diagnostic and therapeutic areas outside clinical
hypnosis, we could call psychosomatistic. This orientation is a constant
xii EXTRACTS FROM FOREWORDS TO SECOND AND THIRD EDITIONS
element which becomes more and more evident as one reads on. It concerns
both the patient with his symptoms and the factors preceding and
concurrent with the induction and deepening of the hypnosis responsible
for these processes, as well as their spontaneous and induced phenomena,
not to mention their therapeutic action. Here we should also note the
importance given to the doctor figure, characterized by affective sensitivity,
inner opening and a capacity for human contact, leading him to accept and
use what the patient initially offers him, displaying trust, respect, empathy
and sympathy, and forming together with the patient a unity made up of
intimate responses.
A clear example of this is the studied attention devoted not only to words
but also to pauses; in other words, the weighing up and interpretation of
the possible significances behind the frequency, duration and quality of
both utterances and silences, and an assessment of how and when they are
inserted into the thread of sound.
It can therefore be especially recommended both for the valuable information
concerning professional practice in many specialist areas and also
because it may help to spread the understanding that it is possible to be
therapeutic purely as a person, sometimes even without the need to resort to
any other remedy.
Gualtiero Guantieri
Foreword to the fourth edition by
Peter B. Bloom
My copy of the original edition of John Hartland's landmark text Medical
and Dental Hypnosis and its Clinical Applications is dog-eared from my close
study and underlining as I worked hard to add this clinical skill and experimental
understanding to my work in medicine and psychiatry. As later
editions became the standard text for succeeding generations of clinicians
and researchers, the field of hypnosis grew with vigor and influence and
entered a new period of acceptance and inevitable controversy. A few years
after Dr David Waxman authored the third edition in 1989, it became apparent
that we needed a further edition that leapt ahead of the previous volumes
and which encompassed a clinically useful and scientifically rigorous
integration of the enormous changes taking place in our field during the
last decade. This is that book.
Michael Heap is a psychologist and Kottiyattil Aravind is a physician.
They have each brought an exemplary level of scholarship and clinical
experience to the rich traditions of clinical practice and experimental
thought. Their differing backgrounds bring a freshness to this book that
reflects the extensive contributions to our field by clinical psychology in the
last forty years. But they do not depart from Hartland's own special stamp.
The essence of Hartland's approach to hypnosis permeates the discussions
on establishing a therapeutic alliance, making a sensible diagnosis, and
planning treatment accordingly. In 1974, he stated to a gathering of clinicians
in Australia that ego-building was the sine qua non of effective therapy.
I am happy to see his original ego-strengthening routine is preserved in this
edition; it still deserves our attention.
In the clinical section of this book, the use of hypnosis in an extensive variety
of medical, dental, and psychological conditions is spelled out in learnable
detail. Gentle are the interventions suggested for approaching patients
dying of cancer or suffering disabling anxieties that limit their lives.
Vigorous are the interventions that are brought to bear on relieving pain in
obstetrics and dentistry. Those who seek a book on how to do hypnosis in
these patients will not be disappointed. Similarly, those with a great deal of
experience will be quickly surprised to find case examples that will help
them find new ways to treat the most difficult patients we see in our offices
throughout our careers. There is much in this volume for every clinician.
The most noticeable change in this edition is its increased reliance on
good scientific thinking. The reader will find clear and logical descriptions
of the evolution of what we know from the laboratory and what we do not
know. In recent years, the neurophysiological basis for response to hypnotic
imagery for pain relief has become clearer, while the manner in which
memory is stored and retrieved has become the basis of enormous controversy.
Heap and Aravind describe the context in which these latter ideas
have developed, and discuss the cultural soil which has allowed them to
grow in some countries but not in others. Beginners reading this text will
understand quickly what has evolved and be able to take their own position
on these issues with intelligence and discernment. The advanced practitioner
will find these discussions stimulating and challenging, and will
recognize the new light they shed on what we know and believe.
I expect this edition will become dog-eared and underlined by many
readers in the years to come as mine did in the past. For those who have
awaited a definitive, comprehensive text, written by the consistent and
even voices of only two authors, the wait is over. John Hartland would burst
with pride that his tradition of excellence in patient care has been so well
preserved and advanced. Ernest Hilgard, who wrote an earlier foreword,
would compliment the authors on their grasp and respect for the science
undergirding our work. Each would agree that the art of therapy is the
fusion of scientific and clinical knowledge. I congratulate the authors on an
extraordinary achievement.
Peter B. Bloom, M.D.
Past President,
International Society of Hypnosis;
Clinical Professor of Psychiatry,
Swarthmore, PA, USA University of Pennsylvania
June 2001 School of Medicine
Preface
It is 35 years since the first edition of John Hartland's Medical and Dental
Hypnosis. In that time, the book has proved immensely popular as an exposition
of the principles and methods of clinical hypnosis in medical and
dental practice, and as an adjunct to psychological therapy. Thirteen years
have elapsed since the appearance of the third and most recent edition,
authored by the late Dr David Waxman. Hence, if only for the sake of consistency,
the fourth edition is now due. But what sort of book should it be?
Our answer to this question has been to set ourselves several clear aims.
First, we have endeavoured to adhere to the original scope of each of the
previous editions, namely to present a description, with case illustrations,
of the major hypnotherapeutic procedures and techniques that are used in
clinical practice. These are mainly, though not exclusively, confined to
Sections 2 and 3 of the book and are sufficiently detailed, we hope, for the
clinical hypnotist in training.
Second, in Section 1 of the book, we have endeavoured to present an
account of hypnosis that is informed by mainstream psychology and its
related disciplines, and draws upon the scientific evidence that has
accumulated from over 50 years of laboratory investigations. In this task,
we have tried to be descriptive rather than theoretical. However, we do not
accept the traditional view, one that characterised the previous editions of
this book, that hypnosis is a process whereby the hypnotist guides the subject
into a state of trance characterised by hypersuggestibility and greater
access to the unconscious mind. Rather, we consider that, during hypnosis,
subjects actively deploy their skills in an endeavour to achieve the effects
and experiences suggested by the hypnotist. Some subjects are apparently
more successful than others (and we incline to the 'trait' school of thought)
but people can be responsive for more than one reason; that is, more than
one skill, aptitude or process is involved.
While the concept of 'trance' has lost much of its explanatory value,
for clinical purposes at least, it is a useful description of the process of
absorption and detachment from immediate realities that characterises
everyday trance experiences. Some good hypnotic subjects may show a
marked facility for this kind of experience, but we acknowledge that the
relationship between measured hypnotic susceptibility and this characteristic
(which we associate with absorption, although some would also refer
to it as 'dissociation') is only a modest one.
xvi PREFACE
We have made this distinction between suggestibility and absorption
or trance an essential one in our presentation of clinical practices. For some
purposes, an enhanced response to suggestion is an important focus of the
therapy, whereas in others the achievement of a 'deep state of absorption' is
the therapist's aim.
Throughout the book, we have attempted to present clinical practice in a
way that is informed by a rational understanding of the nature of hypnosis
and hypnotic phenomena. However, our rejection of the traditional understanding
of hypnosis does not mean that practitioners who still adhere to
that paradigm may not employ any of the procedures that we describe. To
help the practitioner understand why this is so, in Section 3 we have developed
the concept of the 'working model'. This is a set of assumptions about
the patient's problem and how hypnosis may contribute to its alleviation or
management. A working model may generate therapeutic procedures that
are effective, yet the model itself need not be valid in a literal sense. In such
cases, we can often say that the working model is a 'metaphorical representation'
and we describe in Section 4 how metaphorical models may inform
the effective application of hypnotic procedures to certain conditions and
disorders.
Of metaphorical significance only, in our opinion, is the idea of the
'unconscious mind', and indeed we consider that it is an overvalued, limited
and potentially misleading concept. In Section 3, we make the point
that this has been the fate of a number of useful metaphorical constructs
(including the hypnotic trance and, more recently, ego states) that have
become reified and accorded explanatory powers that they do not possess.
We consider that this is one of the ways that hypnosis has come to be misused
in 'recovered memory' therapy, an example of where a working model
has been extended well beyond its range of useful application, with disastrous
consequences. Likewise, we retain our British scepticism of the use of
hypnosis to diagnose multiple personality disorder, or dissociative identity
disorder, as we are now required to call it, a psychiatric classification rarely
used in the UK.
Instead of the 'unconscious mind', we offer a dynamic (and certainly not
original) working model involving a reciprocal process of unconscious-toconscious
expression of cognition and affect which is facilitated by the encouragement
of overt communication ('talking therapy' being the most common
method). On tins working model, we base our presentation of what hitherto
have been called 'hypnoanalytical techniques' but we avoid this term and prefer
to speak about the psychodynamic application of hypnotic procedures.
In Section 3, we consider how hypnosis may be used within the major
schools of psychotherapy. We use the term 'psychotherapy' in its broadest
sense to include psychoanalytical and psychodynamic therapy, behaviour
therapy, cognitive therapy and humanistic and existential therapy. We
anticipate that many readers will be unclear about these distinctions and
PREFACE xvii
we have therefore presented brief summaries of the principles and practices
that characterise each school. We have also attempted a short and critical
account of the work and influence of Milton Erickson.
We must warn those readers who are familiar with any or all of the above
schools of psychotherapy that they may find our accounts oversimplistic
and at times idiosyncratic. Any idiosyncrasies probably arise first because
we have presented our accounts with a view to describing how hypnotic
procedures may be applied within each of the respective approaches and
second because we set ourselves the task of developing a framework on
which to base an eclectic or integrationist approach to hypnosis in psychotherapy.
There are two reasons for our emphasis on eclecticism. First, many practitioners
of hypnosis are indeed eclectic in their application of psychotherapy,
adopting a behavioural approach with one patient or client, a
psychodynamic emphasis with another, a cognitive emphasis with another,
and not uncommonly a combination of approaches with the same patient,
even within the same session. Second, hypnotic procedures lend themselves
very well to this way of working, allowing the therapist, guided by
the client, to move fluently between the different levels as required. Our
framework for this kind of work is presented in Section 3.
In Section 4, we present applications of hypnosis to specific conditions,
disorders and problems that are commonly encountered in medical, dental
and psychotherapeutic practice. Some problems are covered in greater
depth than others and sometimes we have described non-hypnotic procedures.
In the case of psychological disorders, we can only assume that the
reader intending to use hypnosis for these is already accomplished in their
treatment using non-hypnotic methods. As well as the procedures presented
earlier in the book, we give readers some ideas for using hypnosis
as an adjunct to a broader programme of therapy.
Throughout the book, we give, we hope, due acknowledgement to the
minimisation of risk and to good ethical practice. In the appendices, we
include rules for ethical practice as devised by the International Society
of Hypnosis, and guidelines for using hypnosis for the resolution of early
traumatic memories. Also, in Section 5, we address what we loosely term
'professional issues'. 'What is the evidence that hypnosis is effective?' is
one question which we endeavour to answer by summarising the results
of outcome studies. An impetus for our doing this is that the question is
often asked of doctors, dentists and psychologists who are planning 'hypnotherapy'
clinics or similar projects and have to make a good case when
applying for funding and resources. In the same chapter, we address the
question of whether hypnosis is effective as a method of interrogating
witnesses to crime, and we adopt a critical perspective.
After we have explored the evidence for the benefits of hypnosis, we ask
if the public are at risk from any adverse effects. We explore this question by
xviii PREFACE
considering lay hypnotherapists and stage hypnosis, and we adopt what
we hope is a balanced perspective.
In our final chapter, we offer some advice to the serious practitioner of
hypnosis who wishes to keep abreast of developments in the field and
communicate with like-minded colleagues. In that chapter, we also return
to the theme of the importance of representing and applying hypnosis in a
manner that is consistent with existing knowledge and evidence, not only
of hypnosis itself but of human psychology generally.
If there is only one criterion by which this book is to be evaluated, then let
it be the extent to which we have adhered to the above precept. Of course,
in many disciplines there is always some tension between, on the one hand,
the academics, theorists and researchers and, on the other hand, those
whose job it is to apply the knowledge to real-life problems. In the case of
hypnosis, it is the ideas of the latter which have tended to predominate.
Hence, the way hypnosis is presented and understood is often with disproportionate
regard to the needs and expediencies of the clinical practitioner.
Even amongst those professionals trained in the exacting disciplines of
medicine and psychology, it seems that an interest in hypnosis all too easily
becomes a readiness to accept any fad or fashion that presents itself as a
means of curing the ills of the age. Equally, there is a willingness to provide
intellectual accommodation to the most outlandish notions about the workings
of the human mind, brain and body. It still remains the case that any
page turned at random in any book drawn at random from the hypnosis
shelves of any bookshop will, more likely than not, provide readers with
information that is unreliable, unsubstantiated, or plainly false.
It is regrettable that at the time of writing, in North America at least,
where much of the progress in our understanding of hypnosis and the
scope of its therapeutic applications has originated, the gulf between the
theorists and the practitioners could hardly be wider. This state of affairs
has arisen as a result of therapeutic practices that have been informed by, at
the very best, some highly tenuous assumptions about human memory,
which have little support in academic psychology and experimental hypnosis
in particular.
It is our hope that, whoever the authors are by the time the next edition
of this volume comes to be written, they will be able to report that this conflict
was resolved in a manner consistent with existing scientific knowledge
of human memory and mental processes. No other outcome can be considered
as acceptable.
Note
In this book, we express many beliefs and opinions but it is unrealistic
to suppose that we are always in complete agreement. We do not, however,
consider it useful to readers to air our differences. Hence, statements
PREFACE xix
beginning 'In our opinion' or 'In our experience' may be more representative
of the opinions and experience of one of us rather than the other.
Explicit references to the opinions or experience of just one of us (MH or
KKA) does not imply disagreement; it is simply the case that the other
author has not had sufficient experience to draw on to endorse what is
being stated.
Sheffield 2001
M.H.
K.K.A.
Acknowledgements
We are wholly responsible for the accuracy of the information contained in
this book and the quality of the instructions, advice and guidance we give
to readers, likewise the opinions we express. We have, however, sought
advice on certain topics and accordingly wish to thank the following colleagues:
Dr Richard Brown, Mrs Valerie Heap, Mr Simon Houghton,
Mrs Mary Lea, Professor Leslie Walker, and numerous international colleagues
on the 'research list serve' email network organised by the Society
for Clinical and Experimental Hypnosis.
Professor Paul Salkovskis has very kindly given us permission to present,
in Chapter 21, a modified version of his diagram of the development of
obsessive-compulsive disorder from his chapter 'Obsessions and compulsions'
in Cognitive Therapy in Practice: An Illustrative Casebook, edited by
J. Scott, J.M.G. Williams and A.T. Beck (Routledge, London, 1989).
We are grateful to the Springer Publishing Company, New York, for
allowing us to reproduce, in Chapter 26, the 'Is it possible?' script that
appeared in Hypnosis and Behaviour Therapy: The Treatment of Anxiety and
Phobias by J.C. Clarke and J.A. Jackson (1983).
The British Society of Experimental and Clinical Hypnosis has kindly
allowed us to reproduce, in Appendix 1 to this book, its guidelines
on Clinical Hypnosis and Memory, compiled by Dr David Oakley and
Mrs Marcia Degun-Mather.
We are grateful to the Central Office of the International Society of
Hypnosis (ISH) for allowing us to reproduce, in Appendix 2, the Ethical
Guidelines from the ISH Members' Directory.
We thank Mrs Gwyneth Parry (formerly Benson) for allowing us to
reproduce in detail, in Chapters 14 and 19, her training handouts on using
hypnosis with children and adolescents, and Mr Geoff Callow for providing
us with details of the fantasy procedures that he has recently developed
for children and adolescents, which we have described in Chapter 14.
Finally, we express our gratitude to Ms Inta Ozols, Ms Karen Gilmour
and Ms Alison Ashmore of our publishers Harcourt Health Sciences for
their advice, support and patience while we have been preparing this book.
M.H.
K.K.A.
SECTION 1
The history and nature
of hypnosis
In this section we address the question 'What is
hypnosis?' We first do so from an historical perspective
in Chapter 1. From our brief summary and the ensuing
chapters on the nature and theories of hypnosis, it will
be clear that hypnosis and its forerunner, mesmerism,
are very much social constructs in which the
behaviours and experiences of the participants (both
hypnotists and subjects), and their understanding of
these, are significantly determined by the expectations
and demands of the context (the immediate situation
and the wider social framework) in which the activity
takes place.
Our approach to hypnosis is, however, not simply a
social psychological one, and a review of the theories
and several important research issues in Chapter 4
leads us to emphasise the importance of a range of
cognitive skills that hypnotic subjects are able to deploy
in their endeavour to have the experiences and
respond in the manner suggested by the hypnotist.
Some subjects appear to be better at this than others
and we adhere to the more traditional view that
hypnotic responsiveness is a stable trait (Chapter 3).
We consider that the pivotal concept in hypnosis is
not 'trance' but 'suggestion' (and suggestibility). We
explore both concepts in Chapter 2 and conclude that
'trance' in the sense of absorption on inner experiences
is still of importance, although thus conceived it is of
less explanatory significance than that assigned by
earlier notions.
Theories of hypnosis
Chapter contents
Introduction 41
What should a theory explain? 42
Special-state or special-process theories 42
Problems with special-state theories 47
Non-state or social and cognitive theories of hypnosis 48
Our definition and working model of hypnosis 55
A note on language 56
INTRODUCTION
In this chapter, we shall not attempt a review of all the major theories of
hypnosis. We shall focus on the division between theories that postulate
special or unique mechanisms to account for hypnotic phenomena, and
those that offer explanations in terms of cognitive and social psychological
factors that are common to non-hypnotic contexts. We shall not present an
historical review although we have noted in Chapter 1 how certain historical
figures in the field endeavoured to understand the processes underlying
hypnosis.
It is also worth mentioning here that the great Russian physiologist Ivan
Pavlov developed a theory of hypnosis in animals, the principal underlying
mechanism being inhibition of cortical and then subcortical activity. This is
summarised in a book by the American psychologist William Edmonston
(1981). A modern approach to understanding hypnosis that has been influenced
by Pavlov's ideas is that described by Edmonston in his book (and in
Edmonston 1991). He has postulated that 'neutral hypnosis' (hypnosis
limited to a standard induction and deepening routine) is equivalent to
relaxation and that phenomena that are labelled 'hypnotic' are merely facilitated
by relaxation. Edmonston proposed that we use the word 'anesis' as
a more appropriate term, but this has not proved a popular idea and the
theory has not generated much research activity.
In the 1960s in the UK, the physician Barry Wyke (1957, 1960) put forward
a neurophysiological theory not dissimilar to Pavlov's and based on
the activity of the reticular activating system, a neural network that regulates
arousal and wakefulness. This was influential amongst a number of
41
42 MEDICAL AND DENTAL HYPNOSIS
medical doctors in the UK, but there appears to have been little interest
beyond that.
WHAT SHOULD A THEORY EXPLAIN?
Before examining some modern psychological theories, it ought to be asked
what should be the purpose of any theory of hypnosis. It appears that the
answer to this has something to do with accounting for what some term
'counter-expectational observations'. However, as the expectations of the
hypnotic subjects themselves are an important factor, we shall avoid the
ambiguity of this term by speaking of 'out-of-the-ordinary' observations. A
theory of hypnosis should also explain individual differences in hypnotic
susceptibility and any correlations between hypnotic susceptibility and
other personality factors and dimensions of cognitive style. Let us first,
however, explore what we mean by 'out-of-the-ordinary observations'.
When we observe the behaviour of hypnotic subjects and hear their
accounts of what they experience, we only seek an explanation when what
we have observed or heard from the subject is out of the ordinary, that is,
when it is different from what one normally observes out of the hypnotic
context. For example, suppose a hypnotic subject moves an arm in response
to an arm levitation suggestion. Normally when people are thinking about
their arm and it moves upwards, they report that they are doing this voluntarily,
with conscious effort. So, if hypnotic subjects simply report that they
moved the arm voluntarily, then no special explanation is required.
However, if the subject reports that the arm lifted automatically, without
the subject consciously moving it, then an explanation is called for.
We can argue likewise when, to the appropriate suggestions, subjects
appear to be less sensitive to pain; to be unable to open their eyes, move
their arm, or utter their name; be unable to recall something that they have
just heard; report extremely vivid experiences when they are asked to
imagine being a child again; believe that somebody is standing in front of
them when such is not the case; report that they are unable to see something
that is in front of them; are unable to hear a sound, such as their own voice;
and carry out an instruction, given some time previously, in an apparently
automatic and compulsive manner.
SPECIAL-STATE OR SPECIAL-PROCESS THEORIES
Although we require explanations for all of these observations, it does not
immediately follow that we need special processes or mechanisms that are
different from those we use to explain observations that are not 'out of the
ordinary'. However, special-state or special-process theories do just this by
hypothesising that when people are subjected to a hypnotic induction, they
are in some special state of consciousness, different from the ordinary
4: THEORIES OF HYPNOSIS 43
'waking' state, and which we may call the 'hypnotic trance'. The properties
of the trance are such as to explain all of the above phenomena.
In Chapter 2, we listed several other known altered states of consciousness,
namely sleep, alcoholic intoxication, epilepsy and concussion. We said
that each of these states is associated with certain reliably observed behaviours
and experiences on the person's part and it is commonplace to explain
these by saying that they occur because the person is in a state of sleep, in a
state of intoxication, in a state of concussion, and so on. Of course we still
have to investigate what actually constitutes the state in question in order
eventually to fully explain what we are observing. Therefore, it is important
to investigate the nature of this state of hypnotic trance before we can fully
explain the subject's responses and experiences.
The theory of dissociated control
The modern theory that possibly corresponds most with the 'state' or
'special process' approach to hypnosis is a relative newcomer, namely the
'dissociated control' model associated with Erik Woody and the late
Kenneth Bowers of the University of Waterloo, Ontario. This approach
(Woody & Bowers 1994) has the advantage of being based on an existing
neuropsychological model of the voluntary and involuntary regulation of
behaviour, created by Norman & Shallice (1986). This model envisages two
systems that regulate everyday behaviour. The lower-level, 'decentralised'
system consists of units or schemas that govern particular actions. When
a schema is activated at a certain threshold, the corresponding action is
executed. Schemas are activated or inhibited by other schemas or by environmental
triggers. This process is termed 'contention scheduling' and
for well-learned habits this proceeds automatically with little centralised
control.
Often we have to execute a complex or unfamiliar sequence of actions, or
sometimes strong habitual tendencies need to be inhibited. For instance,
with a well-learned activity such as driving a car we can rely a great deal on
contention scheduling. However, sometimes the activity has to be executed
in a different way - for example, when driving the car on the side of the
road opposite to that which is customary. Relying on contention scheduling
here would have disastrous consequences. Now, a higher-level system,
known as the 'supervisory attention system', is able to intervene in order to
control the activation of the schemas, biasing the distribution of activation
according to the requirements of the task. This constitutes the basis of
willed, as opposed to automatic, action.
Woody & Bowers (1994) postulate that hypnosis disengages the supervisory
system from its influence on the lower-level system, and the behaviour
and experiences of the hypnotised subject are more automatically triggered
by the hypnotist's suggestions.
44 MEDICAL AND DENTAL HYPNOSIS
According to Norman & Shallice (1986), the supervisory system is a function
of the frontal lobe. Damage to the frontal lobe will interfere with this
function and is associated with problems in the planning and regulation of
behaviour and in the inhibition of automatic responses. Hence, a hypnotised
subject behaves like a patient with frontal lobe damage, responding in
a genuine automatic and involuntary manner to the suggestions and
instructions of the hypnotist.
In support of this is some neurophysiological and neuropsychological
evidence consistent with the idea that during hypnosis, in highly susceptible
subjects, the activity of the frontal lobe, notably on the left side, is attenuated
(see Gruzelier 2000 for a summary of this). A problem for this theory,
however, is explaining self-hypnosis and self-suggestion and it fails to
account for a range of observations that will be shortly described.
Neo-dissociation theory
Woody & Bowers (1994) contrast their dissociated control model of hypnosis
with the neo-dissociation model of Ernest Hilgard (1986). Hilgard
adopted a broader definition of dissociation than Janet (see Ch. 1), one that
underlies a whole range of everyday phenomena. Unlike the theory of dissociated
control, Hilgard's model assumes that the actions of the hypnotised
subject are controlled in the normal way; it is the subject's awareness of
this that is dissociated.
Let us first give further consideration to the regulation of behaviour.
Imagine that you are driving to a meeting at which you will be expected to
give a presentation. Unfortunately you have not yet prepared what you are
going to say and you are spending much of the time rehearsing this in your
mind. At the same time, you are having to execute a perceptual-motor skill of
the highest order, namely drive your car. Somehow you manage to focus on
the cognitive rehearsal of your talk sufficiently, even though you also successfully
operate the car and negotiate the traffic. Indeed, you are doing this so
well that you cannot even recall certain parts of your journey. Suppose, moreover,
you are giving a lift to a colleague who insists on telling you about his
holiday. Somehow you are managing to process the information he is giving
you sufficiently to be able to make the right sorts of comments, such as 'How
nice!' when he tells you how friendly the people were and, 'Oh dear!' when
he tells you that his wife fell over and hurt her knee. While all this is going on,
from time to time you notice you have a headache, while, at other times,
although the headache does not exactly disappear, you somehow 'forget it'.
We can imagine that all this is possible because there is a part of your
mind that controls what requires your attention at any particular time and
yet this does not mean that all the other activities that you engage in have
to stop. Like Hilgard, we can call this part of your mind the 'executive ego'
and all the other units of activity 'cognitive control structures'.
4: THEORIES OF HYPNOSIS 45
Now, the executive ego is limited in the priority it is able to assign to any
particular activity. In the example of your driving to the meeting, there may
be parts of your journey that are unfamiliar to you, or the driving conditions
become very difficult, and it is impossible for you not to give your
attentional priority to your driving and ignore the other activities mentioned.
Thus, Hilgard talks about 'constraints on ego autonomy'.
To simplify his theory, hypnosis and hypnotic suggestions are ways in
which the hypnotist can influence the subject's executive ego in the assignment
of attentional priority to various activities and experiences. Thus,
through hypnosis, experiences and activities that would normally be represented
in consciousness may become dissociated from awareness. Hilgard
uses the concept of 'amnesic barrier' to describe the mechanism whereby
this is achieved. Amnesic barriers have the quality of permeability so that
some processes, experiences or activities may be considered to be highly
autonomous, separated from the rest of the system by an impermeable
amnesic barrier. Others are considerably less so.
This account of dissociated cognitive control structures that are separated
by amnesic barriers of varying permeability forms the basis of a psychodynamic
model of personality structure that has been very influential in
the field of hypnosis. The idea of 'parts' of a personality or 'ego states', will
be discussed in Chapter 16.
The hidden observer
The most famous laboratory demonstrations of Hilgard's neo-dissociation
theory involved the elicitation of profound analgesia in highly susceptible
subjects (Hilgard et al 1975). Subjects are required to keep their hand in a
bucket of ice-cold water and rate the degree of pain experienced on a scale
from, say, 0 to 10. Without suggestions of analgesia, the ratings, given
orally, are towards the upper end of the scale. In response to suggestions of
analgesia, these ratings may come down to the lower end of the scale. In
accordance with the neo-dissociation model, the experimenter then suggests
that there is a hidden, 'unhypnotised' part of the person that is still
experiencing the pain in the usual manner. This 'hidden observer' is asked
to rate the pain experienced on the 0-10 scale in writing, using the free
hand. Typically, these ratings correspond to the pain ratings given without
suggestions of analgesia but still during hypnosis. These experiments have
been repeated using suggested deafness (Crawford et al 1979).
Some writers, for reasons that we will see later, consider that the hidden
observer effect is an artefact created by the experimenter, with the subject
duly complying. Other people have taken it more seriously. For example,
Watkins & Watkins (1990) consider that when hypnosis is used for pain
relief, and indeed when patients undergo any analgesic procedure, there is
a hidden part that is feeling the pain that would normally be present at a
46 MEDICAL AND DENTAL HYPNOSIS
conscious level. Watkins & Watkins (1990) consider that this is not without
adverse consequences for the patient. In the present authors' opinion, however,
this is an example of an idea taken beyond its useful sphere of application.
Indeed, it is not clear where the hidden observer effect fits in the
alleviation of clinical pain through hypnosis (see Ch. 26).
It is worth mentioning here the work of the late Professor Martin Orne at
Harvard University. Like Hilgard, Orne has been one of the commanding
figures in the field of modern hypnosis. Although it seems that he tended to
adopt a state orientation, he nevertheless conducted some influential
research on the role of contextual demands and social pressures in hypnotic
phenomena. Orne (1959, 1962) considered that there were observable differences
between the behaviour of susceptible subjects during hypnosis
and those instructed to simulate hypnosis. The differences hinge on a concept
that he termed 'trance logic'. For example, he demonstrated that genuine
hypnotic subjects, when asked to hallucinate a person sitting in a chair
in front of them, would also describe objects that would ordinarily be
obscured by the person's body. This is of course illogical. Simulators tended
to deny being able to see the objects because the hallucinated person was in
the way. Orne also reported that true hypnotic subjects, as they traversed
the room, avoided colliding with a chair for which they had been given a
negative hallucination suggestion. Simulators tended to bump into the
chair, as one would logically expect. In another demonstration of trance
logic, Orne (1972) regressed a student to a time when he was unable to
speak English. Orne conversed with him in his native tongue (German) and
then suddenly asked him 'Do you speak English?' Variations of this question
were given and each time the student replied 'Nein'. Again this is
illogical. (This effect can also be demonstrated by regressing subjects to
their early years and asking them questions in a vocabulary that they would
not at that time understand; they still tend to respond to the questions.)
Trance logic' is the ability to hold two contradictory beliefs or pieces of
information in mind without experiencing the usual sense of conflict, and
this may be understood in dissociative terms. Needless to say this concept
has its detractors. For example, in the positive hallucination test, it may
simply be that hypnotic subjects create a transparent image of the person.
Although it may be debated whether the neo-dissociation theory is actually
positing a 'special state', Hilgard is clear that some important change is
happening when a person is subjected to a traditional hypnotic induction.
He says:
Looked at in other ways, we find that hypnotic procedures are designed to produce
a readiness for dissociative experiences by disrupting the ordinary continuities of
memories and by distorting or concealing reality orientation through the power
that words exert by direct suggestion, through selective attention or inattention
and through stimulating the imagination appropriately.
(Hilgard 1986, p 226)
4: THEORIES OF HYPNOSIS 47
PROBLEMS WITH SPECIAL-STATE THEORIES
The major theoretical controversy in the field of hypnosis over the last 50
years has been whether special processes (such as, although not exclusively,
a trance state) are required to explain hypnotic phenomena, notably the
kind of out-of-the-ordinary observations listed earlier.
A longstanding criticism of the 'special-state' way of understanding
hypnosis runs as follows. Suppose we say 'John is slurring his speech
because he is in a state of intoxication', or 'Mary is not responding to us
because she is in a state of sleep'. We can answer the questions 'How do you
know that John is intoxicated?' and 'How do you know that Mary is
asleep?' by reference to some defining property of the state in question that
is independent from the observations we have made. That is, we can say
that John is slurring his speech because he is intoxicated and we know that
he is intoxicated because we have just done a breathalyser or blood test.
Likewise we can say that Mary is not responding to us because she is asleep
and we know that she is asleep because we have tested this by observing
her EEG.
Unfortunately, we cannot do this with our explanation that a subject's
behaviour and experiences occur because the subject is in a hypnotic trance.
We cannot test our explanation by referring to some independent objective
marker that reliably indicates that a trance state is present. It is true that,
particularly in recent years, neurophysiological correlates of responses to
specific hypnotic suggestions have been identified in certain highly responsive
subjects and these differ from those observed in subjects of low susceptibility.
However, there is no known physiological marker that identifies
the 'state of hypnosis' across the range of out-of-the-ordinary phenomena
such as is provided by the examples given earlier. However, this is not to
say that one day an objective marker that distinguishes the 'hypnotised'
from the 'non-hypnotised' subject will not be found.
In Chapter 1, we referred to an important principle that underlies rational
thinking and the scientific method, namely Occam's razor. This states
that we should try to explain things in terms of what we already know
and understand, before we resort to hypothesising the existence of special
entities, forces, energies, and so on. The implication of this is that those
who do invent a special construct to explain a set of phenomena are
the ones on whose shoulders the burden of evidence rests in demonstrating
that such an entity exists or is required to exist by the available
evidence.
In fact, in contradiction to this, it is not unusual for much scientific
enquiry to be invested in attempting to refute the existence of some hypothesised
construct or entity. In Chapter 1, we saw how the Royal Commissioners
investigated Mesmer's practices and concluded that there was no
evidence to support the existence of animal magnetism.
48 MEDICAL AND DENTAL HYPNOSIS
NON-STATE OR SOCIAL AND COGNITIVE THEORIES
OF HYPNOSIS
Over the last 50 years, an increasing number of investigators have come to
acknowledge the central importance of normal psychological processes in
accounting for the behaviour and experiences of the hypnotic subject.
Indeed, many respected authorities go so far as to assert that the only
unusual characteristics of hypnosis are the expectations and beliefs held by
both the hypnotist and the subject.
Nobody, in fact, would seriously contest that everyday psychological
processes are involved in responding to hypnotic procedures. Clearly one
ingredient is selective and sustained attention, and, as we previously noted,
absorption. At least with regard to neutral hypnosis, mental and physical
relaxation is normally a major feature. Also, much of hypnosis requires subjects
to deploy their imagination. Indeed, one of the major figures in the
'non-state' approach to hypnosis over the last half-century, the American
psychologist T. X. Barber, made imagination (or the ability to fantasise realistically)
one of the central features of his understanding of hypnosis (see
Barber et al 1974). In support of this is the higher-than-average hypnotisability
of individuals who have a propensity for vivid fantasy (see Ch. 3).
Also, Barber and his colleagues (see Ch. 7) demonstrated the equivalence of
'task-motivating' instructions to traditional trance-inducing procedures in
enhancing suggestibility.
Another ingredient of hypnosis is expectancy. The hypnotist creates
the expectancy in subjects that they will have certain experiences and
responses and, in a motivated subject, some would assert that this is sufficient
for those experiences to occur. Although others would argue that
expectancy effects are only a by-product of hypnosis, at least one authority,
Irving Kirsch, a psychologist at the University of Connecticut, considers
that response expectancy is the essence of hypnosis (Kirsch 1991). He and
others have demonstrated experimentally how responsiveness to hypnotic
suggestion can be modified by manipulating expectancy on the subject's
part.
In these accounts of hypnosis, therefore, no special processes are required
to explain the observed phenomena. But how does one account for the outof-
the-ordinary effects of hypnosis outlined earlier? All of these appear to
be radically different from one's everyday experience.
Compliance
If readers examine again the list of out-of-the-ordinary phenomena, one
important consideration may present itself. The authenticity of each one
relies on one crucial condition, namely that the subjects' behaviour and verbal
accounts accurately represent their private experience. For example, if
4: THEORIES OF HYPNOSIS 49
subjects say they cannot see something in front of them, then it is assumed
that they are being truthful, likewise if they say they cannot remember
something they have just been told. Similarly, if subjects do not show evidence
of discomfort when a painful stimulus is applied, we assume that it
is because they are not in pain, not that they are consciously suppressing
the reaction.
Now, one characteristic of good hypnotic subjects that experts are agreed
on is that they are very vigilant and sensitive to whatever the hypnotist is
expecting of them. Therefore, how can we be sure that the subject is not just
being compliant? 'Compliant' here means that subjects give the overt
response that the hypnotist appears to be expecting, but this conflicts with
their subjective experience.
The answer is that it is very difficult to tell. Indeed, this fact is exploited
in experiments on hypnosis that require non-hypnotised control subjects
to be placed under the same demands as the hypnotised subjects. These
'simulators', as they are called, are instructed to do their best to fool the
experimenter, so that the experimenter cannot detect that they are not hypnotised.
Setting aside Orne's experiments described above, invariably they
succeed.
The obvious answer to our earlier question would seem to be that simulators
know that they are simply complying and genuine hypnotic subjects
know that they are really experiencing the suggested effects. Hence, all one
has to do to find out who is who is to ask them. Unfortunately, this is not as
simple as it seems. Let us explore why this is so.
Probably for all non-state theorists, it is not possible to explain hypnotic
phenomena without reference to the subject's efforts to satisfy the demands
and expectations that are created by the hypnotic context, that is the situation
in which it is conducted and the actions and communications of the
hypnotist. Indeed, it needs always to be acknowledged that in most contexts
in which hypnotic subjects find themselves - the laboratory, the clinic,
in front of an audience, in a forensic interview - there are social forces independent
of hypnosis that exert a powerful influence on the individual's
behaviour. Hence, there will be a marked tendency for people in such situations
not only to be coerced into doing whatever is required of them, but
also to exhibit compliance, that is to engage in deception, in order to meet
the contextual demands.
At least one theorist, the British psychologist Graham Wagstaff at the
University of Liverpool considers that compliance is a major component of
hypnotic responding (Wagstaff 1981,1991). Coming from the standpoint of
role theory, two American psychologists, Theodore Sarbin and William Coe
(Coe & Sarbin 1991, Sarbin & Coe 1972) have come to a similar conclusion.
For them, hypnotic subjects, to a greater or lesser degree, are so motivated
to play the role of the good hypnotic subject that they will, where necessary,
engage in deception to comply with that role.
50 MEDICAL AND DENTAL HYPNOSIS
What evidence informs us that these explanations require serious consideration?
First, consider this experiment. Highly hypnotisable subjects were
each given the suggestion that they were selectively deaf to their own voice.
Those subjects who indicated that they could not hear their voice were
asked to speak under a condition called delayed authority feedback (DAF)
where the subject's voice is played back to the subject over earphones with
a slight delay. It is very difficult to speak normally under such conditions;
voice pitch and volume rise and speech become dysfluent. What happened
in the case of those subjects who responded positively to the selective deafness
suggestion? DAF had the usual effects on their speech (Barber &
Calverley 1964, Scheibe et al 1968).
Now consider these experiments. Highly hypnotisable subjects responded
positively to the suggestion of posthypnotic amnesia for some material
presented during hypnosis. The suggestion had specified that the amnesia
would immediately lift when the hypnotist gave a certain signal, but
instead of giving the signal, the experimenters put increasing pressure on
the subjects to be honest. One procedure involved connecting subjects to a
'lie detector'; in another condition, 'amnesic' subjects were informed that
good hypnotic subjects would, in fact, be able to recall the material at that
stage. What happened? Nearly all subjects exposed to such pressures
breached their amnesia, whereas those who were not, did not do so (Coe &
Sluis 1989, Coe & Yashinski 1985, Howard & Coe 1980).
Now consider this interesting experiment. After testing, 15 out of 45
highly hypnotisable subjects professed that they saw nothing on a piece of
paper on which was clearly written the number '8'. They had all previously
been given the hypnotic suggestion that on opening their eyes they would
see a piece of paper that was entirely blank. Here is a striking demonstration
of a negative hallucination. However, the 15 subjects were then interviewed
by a different experimenter who asked them to draw what they had
seen. Before they did so, she informed them that people who are faking
hypnosis always say that they see nothing, whereas genuine hypnotic subjects
initially see something written on the paper which then fades from
view. What happened next? Fourteen of the 15 subjects drew the number '8'
(Spanos et al 1989).
Finally, consider this experiment. A group of highly hypnotisable subjects
were informed, in the manner of Hilgard's hidden observer paradigm, that
a hidden part of them was experiencing the actual pain as they were
responding to suggestions of analgesia. As in Hilgard et al (1975), the hidden
observer responded with realistic ratings of the level of pain, in contrast
to the low levels reported overtly by the subjects. In another condition,
subjects were again told that they possessed a hidden observer, but were
not informed of the level of pain that it was supposed to experience. Finally,
in a third condition, subjects were told that the hidden observer experienced
even less pain than the 'hypnotised part' during the hypnoanalgesia
4: THEORIES OF HYPNOSIS 51
test. What were the ratings of the hidden observer in the second and third
conditions?
The answers are that in the second condition the hidden observer's pain
ratings did not differ from the rating of the 'hypnotised part', and in the
third condition they were lower than those ratings (Spanos & Hewitt 1980,
Spanos et al 1983).
What are these experiments telling us? One interpretation could be that
individuals who are reported to be highly hypnotisable are complying, or
less charitably, faking, in order to keep up the pretence of being a deeply
hvpnotised person.
Strategic enactment
The foregoing is a selective and deliberately one-sided account of certain
experimental work that challenges some basic assumptions about hypnosis
that often go unquestioned by clinicians and by the public at large. There
are, however, processes at work in the hypnotic interaction, in addition to
these, that do not imply that the subject is having no experience at all
related to the suggestions.
For example, an important process is 'strategic enactment', an idea promoted
by the late Professor Nicholas Spanos, a psychologist from Carleton
University, Ottawa, and the most prolific figure in academic hypnosis in the
latter part of the 20th century. Professor Spanos was tragically killed in 1994
when the plane he was piloting crashed.
Spanos adopted a strong, non-state, sociocognitive position on hypnosis
(Spanos 1991). He acknowledged the role of compliance in hypnotic
responding, but developed the theme of strategic enactment. He considered
that, in contrast to special-state formulations of hypnosis, hypnotic responding
is goal-directed activity on the subject's part. That is, unlike accounts
provided by dissociation theories, the subject is not passively 'letting things
happen' but actively 'making things happen'. For example, when attending
to the arm levitation suggestion, the responsive subject does not wait for
the arm to rise but lifts the arm, attempting to create, through imagination, the
feeling that it is being pulled up. When given suggestions of analgesia, the
subject adopts a cognitive strategy (e.g. self-distraction) instead of simplv
waiting for the suggestion to take effect. When tested for suggested posthypnotic
amnesia, the subject is not struggling to recall the lost information, but
adopting a strategy, such as attention switching, that disrupts recall.
Now, what implications does this have for our understanding of individual
variations in hypnotic susceptibility and its apparent stability over
time? One possibility is that at least some people who respond poorly to
hypnotic suggestions may have the wrong attitude. For one reason or
another, they do not allow themselves to be actively engaged in utilising
their cognitive skills to make the suggested responses happen, as is the case
52 MEDICAL AND DENTAL HYPNOSIS
with more 'hypnotisable' people. Is it possible, then, that we could train
them to adopt the correct approach and thus increase their hypnotic susceptibility?
And would this training have a permanent effect?
These questions define a major project that Spanos and his colleagues
and students engaged in from the early 1980s onwards. They developed a
training programme called the Carleton Skill Training Program (CSTP).
This is now available in published form (Gorassini & Spanos 1999). The
aims of the programme are to instil in subjects a positive attitude to hypnosis
(by dispelling misconceptions, and so on); to encourage the belief in subjects
that they too can be responsive hypnotic subjects; and to educate the
participants in the idea that to be a good hypnotic subject one has to be
actively involved in creating the suggested experiences and responses,
rather than to passively wait for them just to happen. The latter aim is
achieved by taking the subjects through a range of suggestions (e.g. arm
levitation, finger lock, book hallucination) and coaching them in the 'strategic
enactment' of each one. Advocates of this approach claim that it leads
to a permanent increase in hypnotic suggestibility (Spanos et al 1988).
Others remain unconvinced (Bowers & Davidson 1991).
The position of the authors on this tends to be with the latter group. We
acknowledge that no single process underpins hypnotic responding, and
'strategic enactment', as described by Spanos, is likely to be involved in a
significant way. However, it seems probable that the CSTP is training individuals
in just one way of responding to hypnotic suggestions, but not
necessarily the way of all untrained, highly responsive subjects. Also, we
are not satisfied that the results adequately account for the individual differences
and the stability of susceptibility that both occur naturally. There is
now evidence that at least some susceptible individuals are different from
unsusceptible subjects on cognitive tests involving attention, and on neuropsychological
and neurophysiological measures, both in and out of the
hypnotic context (Crawford 1994, Gruzelier 1998). Neurophysiological
studies (Barabasz et al 1999, De Pascalis 1999) have revealed that some
highly susceptible subjects are having genuine experiences (e.g. profound
analgesia and reduced perceptual responses when imagining visual and
auditory blocking stimuli) rather than responding compliantly.
Attribution
One problem for sociocognitive theories is that, to a significant degree, subjects
report that the effects of suggestions tend to operate in an automatic
fashion and that, for the most part, they are not deliberately enacting them.
Good hypnotic subjects regularly insist that they are, or have been, hypnotised.
How do we account for this?
It is not uncommon in certain contexts for hypnotic subjects to be surprised
by their behaviour during hypnosis. To them it is 'unusual' and thus,
4: THEORIES OF HYPNOSIS 53
unlike 'usual' behaviour, requires an explanation. This is especially so in
the case of stage hypnosis, when participants may find it difficult to account
for why they did the things they did and seemed to be under the control of
the hypnotist. A ready explanation is available to them, namely that they
were 'hypnotised' or 'in a trance' and this is the one they will often adopt.
(If, instead, they had received an appreciable fee for their performances,
probably their explanation would be 'I did it because I was paid to'.) A
laboratory equivalent of this is the study of the behaviour of hypnotic subjects
who respond positively to suggestions that require them to engage in
a dangerous or anti-social activity (Coe et al 1972, Levitt et al 1975,O'Brian
& Rabuck 1976, Orne & Evans 1965). The validity of the attribution 'I did
this because I was hypnotised' or 'I was in a trance' can then be tested by
studying the behaviour of non-hypnotic subjects who are placed in the
same conditions and subjected to the same contextual demands, and who
have the same degree of commitment to participating. The differences
between hypnotised and non-hypnotised subjects are, in fact, non-existent
or, if anything, there is greater compliance by non-hypnotised subjects.
Hence the attribution 'I behaved like this because I was hypnotised' is not
supported. The factors determining the behaviour in question appear to be
non-hypnotic - role demands, expectations, and so on.
Can we apply the same analysis to subjective experience as opposed to
overt behaviour? There is no reason why not. We seek to make sense of our
internal experiences - sensations, feelings, ideas, emotions - particularly
when we observe out-of-the-ordinary changes in them. Obvious everyday
examples are pain and uncomfortable physical symptoms, tense feelings,
mood changes, and so on. We tend to look for external cues, causative factors
and confirmation (as when we seek our doctor's opinion on the reason
for our pain and discomfort) to make sense of these private experiences.
So, consider the hypnotic subjects who, by actively deploying their repertoire
of cognitive skills, successfully reduce their experience of a painful
stimulus, disrupt their recall of a set of words they have only just heard,
allow their arm to lift seemingly without effort or vividly relive a childhood
memory. They may attribute these changes as a product of their own goaldirected
activity, but they may also refer to important external cues and
information that are telling them that what they are experiencing is 'happening
to them', is involuntary, and is the result of their 'being hypnotised'.
Evidence that the interpretation 'voluntary' or 'involuntary' is influenced
by context is discussed by Lynn et al (1990).
Self-deception
We can go even further than the idea of modification of attribution by context.
To what extent are we ourselves able to control the way we interpret
our own experiences and behaviour? One idea that Coe & Sarbin (1991)
54 MEDICAL AND DENTAL HYPNOSIS
have drawn on is 'self-deception'. For example, not all hypnotised subjects
breach posthypnotic amnesia under pressure, or modify their accounts of
their hypnotic experience when the demands are changed. Perhaps these
subjects are deceiving themselves as well as the hypnotist and other
observers. That is, they are required to behave 'as if' they are amnesic and
they come to believe it.
At first sight, 'self-deception' may appear to be no more than a convenient
label for those residual observations that do not accord with the
theory - the pieces of the jigsaw that don't fit. But let us give this idea the
benefit of some further thought.
In order to be consistent with any valued role that we are occupying at
any time, we often have to engage in varying degrees of deception. That is,
we deceive those who expect us to behave in accordance with that role. This
deception is conveyed by our behaviour, both verbal and non-verbal. For
example, patients will expect their doctor to care about them and to be
knowledgeable about their medical condition. Yet doctors may be so exasperated
by what they regard as the unreasonable demands of particular
patients that they feel unable to care about them at all. Moreover, they may
have little idea what the patient's medical problem is or what can be done
about it. However, to maintain the role of a good doctor, a role that the doctor
highly values, the doctor's overt behaviour and speech will communicate
care, concern and competence.
So we deceive others, but can we deceive ourselves in a similar way?
The answer has to be 'Yes', if we bear in mind that deception, and our
awareness that we are engaging in deception, are not all-or-none matters,
but are a matter of degree. In Coe & Sarbin's (1991) terms, we have the ability
to conceal things - that is, to 'keep secrets' - from ourselves in order to
maintain consistency with our 'self-narrative', the story we tell of ourselves
to others and to ourselves,
For instance, as required, 'amnesic' hypnotic subjects behave as if they
have no control over their memory processes. When asked to report directly
on this, under greater pressure, most will eventually change their story and
thus demonstrate that they do have control over their memory. But others
may conceal this from their own self-awareness, and continue to play the
role of the amnesic subject.
What readers must decide
What do readers make of all this? Have the traditionalists successfully
demonstrated that special processes are required to account for hypnotic
phenomena? Are the sociocognitive theories 'specious' as one authority has
lately called them? Or have they enriched our understanding of what goes
on during this peculiar interaction handed down by history? Do their
explanations amount to no more than simply putting what for them are
4: THEORIES OF HYPNOSIS 55
more acceptable labels on what is observed? Is the special proeesssociocognitive
debate merely a conflict of semantics?
One conclusion that readers may come to is that perhaps all the theorists
we have mentioned are like the proverbial group of blind people trying to
discover what an elephant is, each only feeling just one part. Indeed, some
authorities have provided explanations of hypnotic phenomena that integrate
information and ideas from a wide range of viewpoints. The work of
the Australian psychologists Peter Sheehan and Kevin McConkey exemplifies
this; their research has been of particular value as it emphasises the
importance of analysing the subject's experiences of hypnotic phenomena
and the importance of the subject's aptitudes and cognitive skills (Sheehan
& McConkey 1982).
Readers must decide for themselves on these matters, but must not rely
on this one chapter. Further study of the literature combined with experience
of using hypnosis is necessary to appreciate the complexities of this
phenomenon.
OUR DEFINITION AND WORKING MODEL OF HYPNOSIS
We ourselves have no new theory to propose but we would like to provide
a full definition and working model of hypnosis that are useful for
clinical purposes and integrate ideas and observations from laboratory
investigations.
Definition of hypnosis
Putting together our previous definitions of suggestion and trance, and our
brief description of hypnotic induction, we can define hypnosis as follows:
The term 'hypnosis' is used to denote an interaction between two people (or
one person and a group) in which one of them, the hypnotist, by means of
verbal communication, encourages the other, the subject or subjects, to focus
their attention away from their immediate realities and concerns and on
inner experiences such as thoughts, feelings and imagery. The hypnotist further
Attempts to create alterations in the subjects' sensations, perceptions, feelings,
thoughts and behaviour by directing them to imagine various events or situations
that, were they to occur in reality, would evoke the intended changes.
Working model of hypnosis
Hypnosis involves the coming together of a number of psychological
processes and skills, including attention (selective and sustained), absorption,
expectancy, imagination and very often, though not always, relaxation.
Good hypnotic subjects are able to manipulate their conscious
experiences - perceptions, thoughts, images, memories, feelings - under
the direction of the hypnotist to attempt to achieve the suggested effects.
56 MEDICAL AND DENTAL HYPNOSIS
Subjects vary in this ability, which is relatively stable. All subjects come
under pressure to fulfil the role of the good hypnotic subject and the
observed behaviours are markedly influenced by the context. Compliance
or deception is likely to be a significant factor underlying the behaviour of
a significant number of subjects. Those subjects who have the ability' to create,
at least to some degree, the suggested effects, may, because of the context,
interpret their experience as the result of their 'being hypnotised'.
They may thus deny their own agency in creating the experiences.
Hypnotic phenomena are not explained by reference to an altered state of
consciousness. However, one dimension of the experience of hypnosis for
which the term 'trance' may be apposite is the extent to which subjects are
absorbed in the suggested experiences, to the exclusion of their immediate
surroundings and concerns. Some individuals may have a marked capacity
to do this and thus resemble what are traditionally described as 'deep
trance' subjects. The role of the hypnotic induction can be construed either
as encouraging this internal absorption or as increasing responsiveness to
suggestions by enhancing motivation, commitment and expectancy.
A NOTE ON LANGUAGE
It is clear that according to this working model, hypnosis is something that
the person does (or more correctly, two people do). Despite this, we are still
saddled with a vocabulary and phraseology based on the traditional interpretation
of hypnosis. Thus we say that we 'induce' hypnosis and 'deepen'
it, that people are 'in' or 'under' hypnosis, or indeed they are 'hypnotised',
('deeply', 'lightly', etc.), that they 'come out of it', and so on. Unfortunately
it is often difficult to change long-established habits of expression.
REFERENCES
Barabasz A, Barabasz M, Jensen S et al 1999 Cortical event-related potentials show the
structure of hypnotic suggestions is crucial. International Journal of Clinical and
Experimental Hypnosis 47: 5-22
Barber T X, Calverley D S 1964 Experimental studies in 'hypnotic' behaviour: Suggested
deafness evaluated by delayed auditory feedback. British Journal of Psychology 55:439-446
Barber T X, Spanos N P, Chaves J F 1974 Hypnosis: Imagination and human potentialities.
Pergamon, New York
Bovvers K S, Davidson T M 1991 A neodissociative critique of Spanos's social-psychological
model of hypnosis. In: Lynn S J, Rhue J W (eds) Theories of hypnosis: Current models and
perspectives. Guilford Press. New York, ch 4, p 105
Coe W C, Sarbin T R 1991 Role theory: Hypnosis from a dramaturgical and narrational
perspective. In: Lynn S J, Rhue J W (eds) Theories of hypnosis: Current models and
perspectives. Guilford Press, New York, ch 10, p 303
Coe W C, Sluis A 1989 Increasing contextual pressures to breach posthypnotic amnesia.
Journal of Personality and Social Psychology 57: 885-894
Coe W C, Yashinski E 1985 Volitional experiences associated with breaching posthypnotic
amnesia. Journal of Personality and Social Psychology 48: 716-722
4: THEORIES OF HYPNOSIS 57
Coe W C, Kobayashi K, Moward M L 1972 An approach toward isolating factors that
Influence antisocial conduct in hypnosis. International Journal of Clinical and
Experimental Hypnosis 20: 118-131
Crawford H J 1994 Brain dynamics and hypnosis: Attentional and disattentional processes.
International Journal of Clinical and Experimental Hypnosis 42: 204232
Crawford H J, Macdonald H, Hilgard E R 1979 Hypnotic deafness: A psychophysical study of
responses to tone intensity as modified by hypnosis. American Journal of Psychology 92:
193-214
De Pascalis V 1999 Psychophysiological correlates of hypnosis and hypnotic susceptibility.
International Journal of Clinical and Experimental Hypnosis 47: 117-143
Edmonston W E 1981 Hypnosis and relaxation: Modern verification of an old equation.
Wiley, New York
Edmonston W E 1991 Anesis. In: Lynn S J, Rhue J W (eds) Theories of hypnosis: Current
models and perspectives. Guilford Press, New York, ch 7, p 197
Gorassini. D R, Spanos N P 1999 The Carleton Skill Training Program for Modifying Hypnotic
Suggestibility. Original version and variations. In: Kirsch I, Capafons A, Cardena-Buelna E,
Amigo S (eds) Clinical hypnosis and self-regulation: Cognitive-behavioral perspectives.
American Psychological Association, Washington DC, ch 6, p 141
Gruzelier J 1998 A working model of the neurophysiology of hypnosis. Contemporary
Hypnosis 15: 3-21
Gruzelier J 2000 Redefining hypnosis: Theory, methods and integration. Contemporary
Hypnosis 17: 51-70
Hilgard E R 1986 Divided consciousness: Multiple controls in human thought and action
Wiley, New York
Hilgard E R, Morgan A H, Macdonald H 1975 Pain and dissociation in the cold pressor test:
A study of hypnotic analgesia with 'hidden reports' through automatic key-pressing and
automatic talking. Journal of Abnormal Psychology 190: 280-289
Howard M L, Coe W C 1980 The effects of context and subjects' perceived control in
breaching posthypnotic amnesia. Journal of Personality 48: 342-359
Kirsch I 1991 The social learning theory of hypnosis. In: Lynn S J, Rhue J W (eds) Theories of
hypnosis: Current models and perspectives. Guilford Press, New York, ch 14, p 439
Levitt R E, Aronoff G, Morgan C D et al 1975 Testing the coercive power of hypnosis:
Committing objectionable acts. International Journal of Clinical and Experimental
Hypnosis 23: 59-67
Lynn S J, Rhue J W, Weekes J 1990 An integrative model of hypnotic involuntariness. (Is
hypnotic behavior truly involuntary?) In: Van Dyck R, Spinhoven Ph, Van der Does A J W,
Van Rood Y R, De Moor W (eds) Hypnosis: Current theory, research and clinical practice.
VU University Press, Amsterdam, p 17
Norman D A, Shallice T 1986 Attention to action: Willed and automatic control of behavior.
In: Davidson R ), Schwartz G E, Shapiro D (eds) Consciousness and self-regulation, vol 4.
Plenum Press, New York, p 1-18
O'Brian R M, Rabuck S J 1976 Experimentally produced self-repugnant behavior as a
function of hypnosis and waking suggestion: A pilot study. American Journal of Clinical
Hypnosis 18:272-276
Orne M T 1959 The nature of hypnosis: Artifact and essence. Journal of Abnormal and Social
Psychology 58: 277-299
Orne M T 1962 Hypnotically induced hallucinations. In: West L J (ed) Hallucinations. Grune
and Stratton, New York, p 211-219
Orne M T 1972 On the simulating subject as a quasi-control in hypnosis research: What, why
and how? In: Fromm E, Shor R E (eds) Hypnosis: Research developments and
perspectives. Aldine-Atherton, Chicago, p 399-443
Orne M T, Evans F J 1965 Social control in the psychological experiment: antisocial behavior
and hypnosis. Journal of Personality and Social Psychology 1: 189-200
Sarbin T R, Coe W C 1972 Hypnosis: A social psychological analysis of influence
communication. Holt, Rhinehart and Winston, New York
Scheibe K E, Gray A L, Keim C S 1968 I Hypnotically induced deafness and delayed auditory
feedback: A comparison of real and stimulating subjects. International Journal of Clinical
and Experimental Hypnosis 16: 158-164
58 MEDICAL AND DENTAL HYPNOSIS
Sheehan P W, McConkey K M 1982 Hypnosis and experience: The explanation of phenomena
and process. Erlbaum, Hillsdale
Spanos N 1991 A sociocognitive approach to hypnosis. In: Lynn S I, Rhue J W (eds) Theories
of hypnosis: Current models and perspectives. Guilford Press, New York, ch 11, p 324
Spanos N P, Hewitt E C 1980 The hidden observer in hypnotic analgesia: Discovery or
experimental creation? journal of Personality and Social Psychology 39: 189-200
Spanos N P, Gwynn M I, Stam H J 1983 Instructional demands and ratings of overt and
hidden pain during hypnotic analgesia. Journal of Abnormal Psychology 92: 479-488
Spanos N P, Cross W P, Menary E P et al 1988 Long-term effects of cognitive skill training for
the enhancement of hypnotic susceptibility. British Journal of Experimental and Clinical
Hypnosis 5: 73-78
Spanos N P, Flynn D M, Gabora N J 1989 Suggested negative visual hallucinations in
hypnotic subjects: When no means yes. British Journal of Experimental and Clinical
Hypnosis 6: 6367
Wagstaff G F 1981 Hypnosis, compliance and belief. Harvester Press, Brighton
Wagstaff G F 1991 Compliance, belief, and semantics in hypnosis: Anonstate, sociocognitive
perspective. In: Lynn S J, Rhue J W (eds) Theories of hypnosis: Current models and
perspectives. Guilford Press, New York, ch 12, p 362
Watkins J G, Watkins H H 1990 Dissociation and displacement: Where goes the 'ouch?
American Journal of Clinical Hypnosis 13: 1-10
Woody E Z, Bower KS 1994 A frontal assault on dissociative control. In: Lynn S J, Rhue J W
(eds) Dissociation: clinical and theoretical perspectives. Guilford Press. New York,
ch 3, p 52
Wyke B D 1957 Neurological aspects of hypnosis. Proceedings of the Dental and Medical
Society for the Study of Hypnosis. Royal Society of Medicine, London
Wyke B D 1960 Neurological mechanisms in hypnosis: Some recent advances in the study of
hypnotic phenomena. Proceedings of the Dental and Medical Society for the Study of
Hypnosis. Royal Society of Medicine, London
SECTION 2
Basic procedures in
clinical hypnosis
In the previous section we developed the concepts of
suggestion and trance. The key distinction between
these two plays a role in determining how hypnosis is
applied clinically. After considering how one prepares a
subject for hypnosis in Chapter 5, we describe a range
of induction and deepening procedures in the following
two chapters. Procedures that are designed directly to
encourage the trance experience are described in
Chapter 6, and in Chapter 7 we describe those that are
aimed at enhancing the patient's responsiveness to the
suggestions and therapy to follow. We include
discussion of the theoretical rationale for this
distinction, which we interpret not as a dichotomy but
as one of emphasis.
Matters of immediate concern to safe and ethical
practice are presented in Chapter 8, a theme to which
we shall return in later sections. Chapter 9 covers
methods and applications of self-hypnosis; these are
consistent with an emphasis on the trance experience.
Chapters 10, 11 and 13 are very much concerned with
broadening the concept of 'therapeutic suggestion' and
its application in clinical practice, while Chapter 12
details a number of common and very useful
suggestive techniques for the control of tension, anxiety
and anger. Finally, Chapter 14 acknowledges that while
children are very good candidates for clinical hypnosis,
the methods so far discussed need to be adapted to
suit characteristics such as their personal interests,
variable attentiveness, and level of maturation.
Self-hypnosis
Chapter contents
Introduction 101
Which procedures? 101
Teaching self-hypnosis 102
The problem of 'finding the right time' 103
Purposes of self-hypnosis 104
The use of taped instructions 104
INTRODUCTION
Whichever of the two approaches to hypnosis is adopted, in many of the
therapeutic applications it is considered advantageous for patients, in their
own time, to rehearse on a regular basis the induction and deepening
procedures used in therapy. Not only does this have the effect of reinforcing
some of the therapeutic work undertaken in the clinic, but it also encourages
a sense of independence and empowerment on the patient's part. The
patient is not simply a passive recipient of the treatment dispensed by the
all-knowing therapist.
In its simplest and most common form, self-hypnosis is a meditation procedure
based on the induction, deepening and alerting routine that has
been found to be most suitable for the patient. When a session of hypnosis
is confined to these three phases, it is often termed 'neutral hypnosis', no
therapy or suggestions specific to the patient's problems being undertaken.
Nevertheless, the regular, self-directed practice of 'neutral hypnosis', as
with other forms of relaxation and self-regulation, such as meditation,
autogenic training and biofeedback, itself has therapeutic benefits. That is,
around 15 to 20 minutes of 'time out' spent in this way have been shown to
reduce the adverse effects of daily stress (Benson 1975).
WHICH PROCEDURES?
Some practitioners encourage their patients to engage in self-hypnosis
after the first session of heterohypnosis. However, it makes sense to
delay self-hypnosis until you are sure that the induction and deepening
101
102 MEDICAL AND DENTAL HYPNOSIS
procedures that you have selected are the most suitable for your patient and
that he or she is sufficiently accustomed to experiencing hypnosis.
It also makes sense to avoid, for the purposes of teaching self-hypnosis,
inductions that utilise overt ideomotor actions. The disadvantage of these
methods is that your patient may wish to use a brief self-hypnosis procedure
in a public situation such as in the dentist's waiting room or on a bus. A
person using an arm-levitation procedure in those situations would become
an object of curiosity amongst those present! (Spiegel & Spiegel (1987) teach
a standard self-hypnosis routine using an eye-roll induction and an arm
levitation that is disguised as a brushing action of the hand against the side
of the head.)
Common procedures to use are characterised by those recommended in
Chapter 6 for treatment approaches based on the 'trance' concept of hypnosis,
and imagery techniques are a natural choice.
A typical standard routine may begin with the Spiegel eye-roll, and eyeclosure
on a prolonged outward breath. If nothing else, this formalises for
the patient the beginning of self-hypnosis. This may be followed by a
relaxed breathing technique (coupled with a cue word or symbolic image
on the outward breath) and then a progressive relaxation procedure, which
should not be too lengthy. Finally, the 'special place' image is a good choice.
It is recommended that patients alert themselves by the counting method
(from 1 to 5 or the reverse, depending on preference) followed by a few
deep breaths and stretching.
TEACHING SELF-HYPNOSIS
The simplest way to teach self-hypnosis is to take the patient through the
chosen induction and deepening routine and then make the following
suggestions:
Whenever you wish to use hypnosis (or relaxation) for yourself, when it is
convenient and safe to do so, all you need do is find a comfortable place where
you can sit or lie down, close your eyes and consciously relax your body.
At this point, you remind the patient of the routine you have chosen,
making liberal use of suggestions that the patient will relax easily, quickly
and deeply, and be fully in control.
Then give the following instructions:
You may remain in this relaxed state as long as you wish, but whenever you
want to alert yourself again and open your eyes, just count down to yourself
from 5 to 1, preparing to open your eyes at the count of 1, and when you open
your eyes, you will feel alert, fully oriented, and ready to carry on with the rest
of the day, feeling refreshed and recharged.
9: SELF-HYPNOSIS 103
Also, if at any time you need to open your eyes and take immediate action - say,
someone calls you or there is a knock on the door or the telephone rings - you will
open your eyes immediately, be fully alert and ready to take the appropriate action.
When teaching self-hypnosis, also give some general positive suggestions
such as:
Each time you use your self-hypnosis, you will find yourself becoming more
relaxed and calm in everyday situations - not just when you're sitting down
relaxing but also when you're up and about, even in those situations in which
you feel tense and apprehensive. You will find you are able to control those
feelings . . . . You control them, they don't control you.
After you have alerted the patient, he or she may then practise the self-hypnosis routine from you ('Good ...
that's fine ... very relaxed ... etc.').
THE PROBLEM OF 'FINDING THE RIGHT TIME'
A good time to do self-hypnosis may be in anticipation of those times or
events in the day when one knows one becomes unduly tense. As a rule, it
is best not to use self-hypnosis when one is sleepy, as the aim is usually
waking relaxation (unless the patient finds that 'having a nap' is the best
way of unwinding). Rossi (1982) suggests that there are natural periods in
the day, coinciding with the 'rest' phase of the biological 'basic rest-activity
cycle', when it is most appropriate to do one's self-hypnosis. Many people,
for example, may find the period after the midday meal coincides with one
of these phases. Indeed, there is some evidence that hypnotic responsiveness
may vary with this cycle (Aldrich & Bernstein 1987).
All this may be hypothetical, as it has to be acknowledged that as a general
rule people find it difficult to commit themselves to regular sessions of selfhypnosis,
and some research on relaxation tapes suggests that patients may
overstate the number of sessions they practise, perhaps to please their therapist
(Hoelscher & Lichstein 1984, Hoelscher et al 1986). Some patients may
have difficulty finding a time when they are on their own and not likely to be
interrupted. Some may leave their self-hypnosis until bedtime; this is not a
good idea unless the problem is insomnia. Many feel guilty about 'doing
nothing'. Some patients are disappointed with the experience of self-hypnosis
and say that they 'do not go as deep' on their own as with their therapist.
The same problems have been reported in the meditation literature and
some authorities have recommended a series of 'mini-meditations' throughout
the day rather than just one full-length session each day (Carrington
1993). Ft may be easier and still very useful, therefore, for patients to do
their self-hypnosis along these lines.
104 MEDICAL AND DENTAL HYPNOSIS
For example, using the standard self-hypnosis routine outlined earlier,
you may suggest that the patient can use all three stages or select just one or
two of them depending on the situation. A quick eye-roll and eye-closure
and a few moments relaxing the breathing (perhaps with an appropriate
affirmation or self-suggestion) need only take a couple of minutes and may
be a good way of calming down, forestalling a more acute stressful reaction,
and 'getting back in control'. With a few more minutes at the patient's disposal,
the progressive relaxation method may be added, or the 'special
place' technique.
PURPOSES OF SELF-HYPNOSIS
The following are common reasons for teaching your patient self-hypnosis.
They will be taken up again in the chapters on specific applications of
hypnosis.
1. A daily period of simple relaxation (15-20 minutes) has been shown to
significantly reduce stress indices (Benson 1975).
2. Self-hypnosis can be used when a person becomes aware that stress
levels are increasing and there is a need to 'regain control'. It has been
demonstrated to be useful in this way (and in 1) with problems such
as asthma, migraine, irritable bowel syndrome and panic disorder.
It may be used to wind down in preparation for sleep by patients with
sleep-onset insomnia.
3. Self-hypnosis can be used as a way of rehearsing affirmations - for
example, the goals and reasons for abstaining from smoking or for
eating sensibly (such as 'tobacco is a poison' or 'I will eat only what my
body requires'), or imagining the results of successful abstention or
sensible eating (wearing favourite clothes again, having the money to
spend on a desired purchase, etc.). This assists in maintaining
motivation and preventing relapse.
4. It can be used to practise anxiety management, anger management and
other self-control procedures, and to rehearse in imagination coping
with future difficult situations.
5. It may be useful in helping patients cope with the pain and discomfort
of certain illnesses.
6. It is useful as a preparation for learning, as being mentally and
physically relaxed and focused facilitates learning.
7. It may help the person become more attuned to inner experiences -
emotions, memories, fantasies, and so on.
THE USE OF TAPED INSTRUCTIONS
Sometimes it is useful to put the procedures on tape for the patient, particularly
if they are complicated, along with additional instructions such as
9: SELF-HYPNOSIS 105
rehearsal of coping strategies. Indeed, patients sometimes request this.
Although patients do value listening to the instructions, they may come to
rely on the tape and not learn much from it. Also the instructions may need
to be modified as the therapy progresses. Some authorities do not regard
taped hypnosis as true self-hypnosis.
If you do provide your patients with a tape, always emphasise that it is to
enable them to learn the procedures for themselves so they can use them in
everyday life without the tape.
REFERENCES
Aldrich K J, Bernstein D A 1987 The effect of time of day on hypnotisability. International
Journal of Clinical and Experimental Hypnosis 35: 141-145
Benson H 1975 The relaxation response. William Morrow, New York
Carrirtgton P 1993 Modern forms of meditation. In: Lehrer P M, Woolfolk R L (eds) Principles
and practice of stress management. 2nd edn. Guilford Press, London, ch 5, p 139
Hoelscher T L, Lichstein K I. 1984 Objective versus subjective assessment of relaxation
compliance among anxious individuals. Behaviour Research and Therapy 22: 187-193
Hoelscher T L, Rosenthal T L, Lichstein K L 1986 Home relaxation practice in hypertension
treatment: Objective assessment and compliance induction, Journal of Consulting and
Clinical Psychology 54: 217-221
Rossi E R 1982 Hypnosis and ultradian cycles: A new state(s) theory of hypnosis? American
Journal of Clinical Hypnosis 25: 31-32
Spiegel H S, Spiegel D 1987 Trance and treatment. Basic Books. New York
SECTION 3
The application of
hypnotic procedures in
psychological therapy
In previous chapters we have stressed the importance
of making explicit the purpose for which any hypnotic
procedure is being applied. This theme is developed in
Chapter 15, when we consider the various approaches
that one might adopt in order to help someone with a
psychological problem. Whenever one engages in any
treatment, it is always based, implicitly or explicitly, on a
set of assumptions about the patient's problem and
how one's intervention can assist with this. We call this
the 'working model'. In psychotherapy there are a
number of major approaches or schools of therapy that
are based on divergent assumptions about how and
why people come to experience problems, and which
inform therapeutic practice accordingly. We present a
review of these in Chapters 16 to 21 and describe the
adjunctive application of hypnosis in each case. We do
not subscribe to any particular school; rather we
contend that hypnosis is especially well suited to an
eclectic therapeutic approach and we develop our
ideas on this in Chapter 22. In Chapter 23 we return
again to considerations of risk and safety.
Ericksonian approaches to
psychotherapy
Chapter contents
Introduction 193
Unconscious resources 194
Utilisation 195
The emphasis on the resolution phase 195
Reframing 196
Trance 197
Erickson's impact on modern hypnosis and psychotherapy generally 197
INTRODUCTION
In Chapter 10, we looked at styles of hypnosis, notably the indirect method,
and in Chapter 13, we covered the use of metaphor and story technique.
Both of these approaches have been promoted by the followers of the
American psychiatrist and psychologist, Milton Erickson (1901-1980). For
many years, Erickson was a leading figure in the field of hypnosis, both as
a clinician and as an investigator of hypnotic phenomena, especially the
more unusual manifestations. However, he is also remembered as an innovative
psychotherapist of unusual insightfulness. In his later years in
Phoenix, Arizona, he became something of a guru figure for young therapists
who were keen to learn from him and train others in his approaches.
That he was such an inspirational figure may be partly due to the physical
disabilities that he had to surmount in his lifetime, including two bouts of
polio, the first of which occurred in childhood and nearly killed him. In his
final years, he was confined to a wheelchair.
Erickson's approach to psychotherapy does not fit neatly into any of the
major schools that we are describing in the present section of this book. His
approach to therapy is often described as 'strategic'. Our impression is that
strategic therapy is usually more often undertaken with couples and families
than with individuals. He appears to have been something of a radical
in his time, if we remember that the orthodoxy then was classical psychoanalysis,
with its strict rules on how analysts conducted themselves and
organised the therapy sessions. For example, Erickson had no problems
about seeing his clients at his own home (where they would see his wife,
children and family pets). Or he might go to their own homes or even meet
193
194 MEDICAL AND DENTAL HYPNOSIS
them somewhere in town. He had no rule about how long a session of therapy
might last; it could be a few minutes or a few hours. Although this is
common enough now, he was unusual at that time in that he would sometimes
see clients with their spouses or families at some or all sessions, and
even spouses in the client's absence. He would tell the client stories about
himself and his life experiences, something that a psychoanalyst and many
psychotherapists would never contemplate doing. He was often very
authoritarian and directive.
He sometimes commanded his clients to undertake some task or even
'ordeal', such as a journey or a new hobby. Sometimes the purpose for this
would not be apparent to the client. For example, he once instructed a
young man with a bedwetting problem to stay several nights in a hotel in a
neighbouring city and, amongst other things, deliberately worry about how
embarrassed he would feel when the maid discovered his wet bed (Haley
1973, p 86-88).
Erickson was also occasionally deliberately offensive. For example, a
man in his 50s who was disabled by a stroke, a very proud Prussian
German, was brought by his wife to see Erickson. He appeared to be
extremely angry by his predicament. Instead of offering him sympathy,
Erickson proceeded to insult him and all his countrymen, telling him that
they were 'horrible animals ... not fit to live' and 'better used for fertiliser'
(Haley 1973, p 310-313). Needless to say, all turned out for the good in the
end!
He also made use of symptom prescription. There are many examples of
this ploy in his work; for instance, he might instruct a client with a weight
problem to go away and gam a specific amount of weight.
Behind all of this seemingly disparate and incoherent way of working, it
appears that Erickson was guided by certain principles and beliefs about
human nature and how people become stuck in their lives.
UNCONSCIOUS RESOURCES
One of the fundamentals of the Ericksonian approach is that clients have
the resources at their disposal to solve their personal problems. In all likelihood,
by the time they have come to therapy they will have tried all
conscious ways to overcome their problem. Hence, the means whereby they
may come to resolve it are not immediately obvious to them. In other
words, the possible solutions may be said to be 'unconscious'. Thus, we
have an 'unconscious mind' that contrasts with the Freudian conception;
namely that it has the potential to be resourceful and creative and it acts in
the best interest of the person. Some Ericksonian writers extend the domain
of the unconscious mind to cover all mental and physical processes that are
not consciously directed; these include the regulation of vital activities such
as respiration, blood flow and digestion.
17: ERICKSONIAN APPROACHES TO PSYCHOTHERAPY 195
So, the therapist does not provide clients with the answers, but helps
clients to discover them for themselves. Clearly, then, the means of solving
a particular problem will not necessarily be the same for two different
clients. Therefore Ericksonian psychotherapy can be construed as being
very client-centred, although, as we have seen, the therapist is often very
active and may be very direct in planning the most appropriate therapeutic
strategy.
UTILISATION
Any attribute, habit or skill however seemingly problematic, has the potential
to be deployed as a positive resource in the person's life. This is not too
controversial if we think, for example, of a characteristic such as aggression,
which may cause someone (and others too) a great many problems, yet can
prove a great asset if re-channelled, say, into some sporting activity. This
approach to a problem is called 'utilisation'.
Strictly speaking, utilisation means to put to good use something that is
not intrinsically designed for the purpose in question. In the clinical context,
this means using for therapeutic benefit whatever is available from the
client or the immediate situation, even what may be regarded as 'problems',
such as resistance. In terms of what we discussed in the last chapter
about 'parts' or 'ego states', we could say that for Ericksonians, every 'part'
is a potential resource.
The most oft-quoted example of Erickson's utilisation approach to hypnotic
induction is the case of the client who arrived for therapy in such a
state of agitation that he could only pace around the room (Erickson 1959).
The most obvious thing for a therapist to do would be to gently encourage
the client to sit down and relax. Instead Erickson asked the man if he would
continue to cooperate with him by pacing the room. Subtly, he then coupled
the man's movements with indirect suggestions of calming down
and relaxing. Thus, eventually the man was able to relax in the chair, and
proved to be a good hypnotic subject.
THE EMPHASIS ON THE RESOLUTION PHASE
In later chapters, we shall describe how psychodynamic applications of
hypnosis based on the idea of unconscious-conscious communication distinguish
exploratory, uncovering and resolution phases of therapy. It is
apparent in Erickson's work that he did not spend much time exploring
and uncovering the causes of the client's problem. His therapeutic focus
seems to have been to enable clients to find their own ways of solving their
problems. In this he seemed to be able to work out just what he needed to
do to help mobilise clients' strengths in such a way that they would come
up with their own solution. Thus his insulting treatment of the 'proud
196 MEDICAL AND DENTAL HYPNOSIS
Prussian' was calculated to help the man harness what resources he had,
notably his own anger, and to direct this to his own advantage. In order to
do this, Erickson had to go against the normal convention, which would be
to offer care and sympathy, or at the very least to be polite, to one who was
disabled and suffering, something which may not have been particularly
helpful to this man.
Another example is his therapy with a couple who had an alcohol
problem (Haley 1993, p 194-195) and whose weekends were particularly
miserable. The obvious course of action of the therapist would have been to
suggest that they make a habit of arranging interesting things to do at the
weekend. Probably they had already tried to discuss this between themselves.
Indeed the outcome of therapy was that they decided to go camping
at weekends, something they really enjoyed. How did Erickson help them
to arrive at this solution? He instructed them to go boating at weekends,
something they both disliked! To make this prescription, Erickson must
have been able to secure their full compliance, and indeed sometimes he
would make no bones about his being the doctor whom the client had to
obey. But he must also have observed the couple very carefully and been
satisfied that this intervention would bear fruit. How it came about was
that eventually the couple came up with their own answer and asked
Erickson permission to go camping instead of boating.
One danger of all this is that admirers of Erickson will try this method out
on their next similar client. We do know of a colleague who was brave
enough to tell us that he once tried Erickson's symptom-prescription
approach with an overweight patient. This patient did not turn up for her
next appointment. When contacted again, she reported that she had felt
very depressed by the therapist's instructions. Clearly, Erickson's methods
are not 'standard techniques'. One must allow for the uniqueness of each
client and make a strategic intervention such as this only after a careful
study of the client and the nature of his or her problem.
REFRAMING
Not dissimilar to the idea of utilisation is 'refraining' (literally to put a
different frame around something). Again what is initially framed as a
problem may be re-interpreted or acknowledged to be an asset or a solution
to a problem. For example, overeating and smoking are acknowledged
problems but both may be construed in positive ways from the client's
point of view. Both may be a way that the person copes with stress and they
may also be ways in which the person self-rewards. They are not the
solutions that the client consciously wishes, so they may be said to be
'unconscious solutions'.
Indeed, some Ericksonian therapists consider that it is important to
'show respect' to the unconscious mind for 'looking after' the client by, for
17: ERICKSONIAN APPROACHES TO PSYCHOTHERAPY 197
example, overeating, smoking, being afraid, being angry, or whatever. This
may be acknowledged by asking the client to internally say, 'Thank you' to
the unconscious mind (or the 'part that is in charge of the problem').
Having thus reframed 'the problem' as one choice that the unconscious
mind has made in order to help the client, the next step is to increase the
range of choices available. So clients do not have to smoke in order to
achieve whatever smoking does for them; other more adaptive or less
destructive solutions may be available. In other words, therapy does not
take choices away from clients; it helps them to discover more choices
for themselves. One ploy that has been described by Grinder & Bandler
(1982) is to ask the unconscious mind (or the 'creative part of the mind') to
generate one or more alternatives and to give a signal (say by raising a
finger) every time a choice has been unconsciously identified. We ought
to mention that some extraordinary claims have been made for this kind
of 'therapy by digital levitation' but no proper evidence has been forthcoming.
(Bandler and Grinder in their various books (Bandler & Grinder
1975, 1979, Grinder & Bandler 1976) claim to have been able to distil the
essence of Erickson's work (and that of others) into a series of 'press button
A, pull lever B' techniques. These seem to bear little resemblance to what
Erickson actually did.)
TRANCE
We have discussed the Ericksonian concept of trance in Chapter 10, a crucial
property being the possibility for clients to suspend their 'habitual frame of
reference' and thus discover other choices. Although Ericksonians adhere to
an altered-state conception of hypnosis, for them trance is nevertheless a
naturally occurring phenomenon, with or without a formal induction.
Thus, say, during therapy there may be times when clients naturally enter a
trance - a momentary state of mind when they are particularly receptive to
what the therapist is communicating. Hence, it is important that the therapist
carefully observes the client's non-verbal behaviour for signs of the
trance (see Ch. 6) in order to maximise the impact of a communication. Such
'moments of trance' may of course be deliberately engineered by the therapist,
as when he or she throws the client 'off guard' by saying something
designed to surprise or confuse the client.
ERICKSON'S IMPACT ON MODERN HYPNOSIS AND
PSYCHOTHERAPY GENERALLY
Erickson was a renowned figure in the field of hypnosis during his lifetime
and he became increasingly so after his death. He did not offer a structured
or systematic theory of hypnosis in the same way as modern influential
thinkers and researchers such as Hilgard, Barber, Spanos and Sarbin
198 MEDICAL AND DENTAL HYPNOSIS
(see Ch. 4). Attempts by his followers to present a theoretical structure sit
uneasily alongside current major theories (Barber 1991, Matthews et al
1993), possibly because of the strong clinical perspective.
Unlike existing theories, his ideas have not spawned a great deal of
research, and some of his assertions about hypnosis - for example, concerning
literalism in the hypnotic trance (Erickson 1980, Erickson & Rossi
1980) and hypnotically suggested deafness (Erickson 1938a, 1938b) - have
not found support (Barber & Calverley 1964, McCue & McCue 1988,
Scheibe et al 1968). He did not conduct controlled laboratory-based experiments
in the conventional manner of modern psychology. He did not
undertake controlled clinical trials on patients.
Even within hypnosis, people seem to have great difficulty conveying in
simple language, 20 years after his death, what exactly his contributions to
hypnosis were. In fact, in the scholarly A History of Hypnotism, by Gauld
(1992), Erickson's name crops up only once in the text (p 579), amidst a list
of people whose contributions the author indicates he has chosen not to
divulge.
Erickson has had little influence in the broader field of psychotherapy,
unlike people such as Carl Rogers, Joseph Wolpe, Aaron Beck and Albert
Ellis. He has made no contribution to mainstream academic psychology or
abnormal psychology.
Some writers have expressed doubts about the authenticity of Erickson's
accounts of his casework. As Gibson (1984, p 255) has said, 'He is the hero
of all his own stories'. These suspicions have been expressed by Masson
(1988), who also questions the ethics of some of Erickson's practices. McCue
(1988) draws attention to disparate verbatim accounts of his interventions
in two of his cases, one being the 'proud Prussian' described above.
The same author complains of the sensational claims Erickson made about
hypnosis, as in the instance of two people whom he claimed had remained
in a trance for 2 weeks, unknown to anyone else.
Unfortunately, it is no secret that since his death, most of the books on
'Ericksonian hypnosis and psychotherapy' and various offshoots such as
'Neurolinguistic Programming' have been less than enthusiastically
received amongst those who bring a more critical attitude to this area.
Within clinical hypnosis, his impact is seen in the proliferation of
Ericksonian societies across the world. It also appears to be obligatory for
lay hypnosis societies to feature 'Ericksonian hypnosis' as a selling point in
their training programmes. Two of his own lasting achievements were the
founding, in 1957, of the American Society of Clinical Hypnosis and,
around the same time, the American Journal of Clinical Hypnosis, of which
he was first editor. Both continue to flourish.
17: ERICKSONIAN APPROACHES TO PSYCHOTHERAPY 199
REFERENCES
Bandler R, Grinder J 1975 The structure of magic. Science & Behavior Books, Palo Alto
Bandler R, Grinder J 1979 Frogs into princes. Real People Press, Maob
Barber J 1991 The locksmith model: Accessing hypnotic responsiveness. In: Lynn S J, Rhue ]
W (eds) Theories of hypnosis: Current models and perspectives. Guilford Press, New York,
ch8, p241
Barber T X, Calverley D S 1964 Experimental studies in hypnotic' behaviour: Suggested
deafness evaluated by delayed auditory feedback. British Journal of Psychology
55: 439-446
Erickson M H 1938a A study of clinical and experimental findings on hypnotic deafness:
I. Clinical experimentation and findings. Journal of General Psychology 19: 127-150
Erickson M H 1938b A study of clinical and experimental findings on hypnotic deafness:
II. Experimental findings with a conditioned response technique. Journal of General
Psychology 19: 151-167
Erickson M H 1959 Further techniques of hypnosis; Utilization techniques. American Journal
of Clinical Hypnosis 2: 3-21
Erickson M H 1980 Literalness: An experimental study. In: Rossi E L (ed) The collected
papers of Milton H. Erickson, vol III: Hypnotic investigation of psychodynamic processes.
Irvington, New York, eh 10, p 92
Erickson M H, Rossi E L 1980 Literalness and (he use of trance in neurosis. In: Rossi E L (ed)
The collected papers of Milton H. Erickson, vol III: Hypnotic investigation of
psychodynamic processes. Irvington, New York, ch 11, p 100
Gauld A 1992 A history of hypnotism. Cambridge University Press, Cambridge
Gibson H B 1984 Review of Rossi E L (ed) 1980 The collected papers of Milton H. Erickson,
vols I- IV. International Journal of Clinical and Experimental Hypnosis 32: 254-256
Grinder J, Bandler R 1976 The structure of magic II. Science & Behavior Books. Palo Alto
Grinder J, Bandler R 1982 Trance-formations. Real People Press, Maob
Haley J 1973 Uncommon therapy: The psychiatric techniques of Milton H. Erickson, MD.
Norton, New York
Haley J 1993 Jay Haley on Milton H. Erickson. Brunner/Mazel, New York
McCue P A 1988 Milton H Erickson: A critical perspective. In: Heap M (ed) Hypnosis:
Current clinical, experimental and forensic practices. Croom Helm, London, ch 24, p 257
McCue PA, McCue E C 1988 Literalness: An unsuggested (spontaneous) item of hypnotic
behaviour. International Journal of Clinical and Experimental Hypnosis 36: 192-197
Masson J 1988 Against therapy Fontana/Collins, London
Matthews W J, Lankton S, Lankton C 1993 An Ericksonian model of hypnotherapy.
In: Rhue J W, Lynn S J, Kirsch 1 (eds) Handbook of clinical hypnosis. American
Psychological Association, Washington DC, ch 9, p 187
Scheibe K E, Gray A L, Keim C S 1968 Hypnotically induced deafness and delayed auditory
feedback: A comparison of real and stimulating subjects. International Journal of Clinical
and Experimental Hypnosis 16: 158-164
Hypnotic procedures in
psychodynamic therapy
Chapter contents
Introduction 217
Ideomotor signalling 217
The sensory-focusing method 225
Age regression 229
Age progression 235
Resolving difficult memories 236
Miscellaneous fantasy procedures in psychodynamic therapy 242
Methods for children and adolescents 250
INTRODUCTION
In this chapter, we shall be presenting hypnotic methods that may be used
within a psychodynamic framework. However, as we shall see in due
course, therapists who are more committed to behavioural and cognitive
approaches may also find many of them useful as adjunctive procedures.
They may all be understood in terms of our presentation in the previous
chapter of the nature of unconscious and conscious activity. As a rule, when
one is undertaking psychodynamic work using these procedures, it is natural
to choose the first approach to hypnosis, described in Chapter 6. This
emphasises absorption on inner experiences and thus is consistent with the
ideas presented in the last chapter.
IDEOMOTOR SIGNALLING
The method of ideomotor (IMR) signalling can be a useful technique provided
that it is applied selectively and strategically. It involves the use of
suggestion to evoke what are ostensibly automatic or involuntary movements.
(We are aware that the issue of what constitutes involuntariness is
by no means clear. For a discussion of this in the context of hypnosis, see
Kirsch & Lynn 1997.)
A good practical introduction to IMR signalling is by an adaptation of
Chevreul's pendulum, described in Chapter 2. We suggest you practise this
with some colleagues before progressing to the main procedure that we
shall describe, namely IMR signals using finger movements.
217
218 MEDICAL AND DENTAL HYPNOSIS
IMR signalling using Chevreul's pendulum
We shall first describe this method by adopting as our working model the
simple metaphor of 'the unconscious mind'. When we describe IMR finger
signals, we shall present variations on how to describe the method to the
subject.
Having established that your subject is responsive to suggestions of various
movements of the pendulum (see Ch. 2), place a blank A4 paper underneath
the pendulum. Ask the subject to fixate the bob of the pendulum and
suggest that deep down in the subject's unconscious mind, he is thinking
about the message 'Yes'. As the unconscious mind is thinking about the
message 'Yes', it will cause the pendulum to move in a particular direction
to communicate that message. Keep repeating the word 'Yes' and observe
how the pendulum moves. Mark the direction with an arrow on the paper
and then repeat the procedure with the message 'No'. You may also elicit
a movement for the message 'I don't know', and perhaps another one, '1
don't want to tell you'.
Then proceed to interrogate your subject's 'unconscious mind' by asking
questions to which the answer is 'Yes' or 'No'. For example, you might ask
the questions 'Is Bill a medical doctor?'; 'Is Bill currently married?'; and
'Has Bill been to Japan?' Of course, Bill could simply answer these questions
orally, but the purpose of the exercise is to familiarise you with the
IMR method.
You may go on to ask about Bill's likes and dislikes. For example, you
could ask, 'Does Bill like football?' You might probe a little deeper and ask
questions such as, 'At the moment, does Bill enjoy his work?' Before you do
this (and this illustrates one use of the IMR signalling method), you could
ask Bill's unconscious mind for permission to ask this question. So the first
question would be 'Is it OK if I ask Bill if at the present time he is enjoying
his work?'
The pendulum method has been used in clinical work as a psychodynamic
technique (Cheek & LeCron 1968). For example, we could ask more
probing questions such as, 'Is Bill's unconscious mind aware of any particular
memory that has a bearing on his present problems?'; or 'Are Bill's
headaches associated with any particular problem in his life?' Nowadays,
however, the preference is to use involuntary finger movements.
IMR signalling using finger movements
There are a number of variations on the IMR finger-signalling method.
(The thumb is included as a potential signaller, while the ring finger
is the least preferred for these purposes because of the difficulty of lifting
it independently.) One normally uses the method when one has undertaken
a hypnotic induction and deepening routine, although it is possible to use
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 219
it 'cold', and some practitioners apply the method in some circumstances
with the patient's eyes open.
Some practitioners stipulate one hand to work with, as with two hands
there is the problem of dividing the therapist's attention. The arm(s) may be
raised in the flexed position so the hand hangs loose; it may be that this
facilitates the automatic quality of the movements. Otherwise the hands
may rest on the lap or arms of the chair.
How you describe the method to the patient depends on your own personal
style. You may refer to 'the unconscious mind' if you wish, as this
makes sense to most patients; or you may talk about 'the back part of the
mind', 'deep down in your mind', or whatever variation you prefer. Some
practitioners communicate the suggestions and questions as if they are literally
talking to a separate part of the mind, as in the illustration of
Chevreul's pendulum earlier. Others prefer to address the questions in the
normal way. This distinction will become clearer below.
If you wish, you can present an everyday rationale to the patient prior to
eliciting the responses. You may say something like:
In everyday life, you communicate not just consciously in words, but also
unconsciously by movements such as gestures of the hand, movements of your
body, and facial expressions. You do these movements unconsciously, without
thinking, but they communicate important messages about your feelings, ideas,
wishes, and so on. For example, when you want to communicate the message
'Yes', you nod your head. When you want to convey the meaning 'No', you shake
your head. You do this automatically (or your unconscious mind/the back part of
your mind does this for you). When you don't know the answer or you don't
want to say, you lift your shoulders, again quite automatically and unconsciously.
Right now, in this same way. you (or your unconscious mind, etc.) can choose a
way of communicating the message 'Yes' by moving one of the fingers or your
thumb on one of your hands (or your right/left hand)... quite automatically and
unconsciously. So deep down, you (or your unconscious mind, etc.) can be
thinking of the message 'Yes'... 'Yes'... 'Yes'... and one of your fingers or your
thumb will lift quite naturally and automatically (or your unconscious mind/the
back part of your mind can choose one of your fingers ... etc.) to convey that
message 'Yes'... 'Yes'... 'Yes'....
Sometimes the movements are unconscious in the sense that the patient is
ostensibly not simply unaware of any conscious intent to move the fingers, but
is also unaware that the movements are occurring at all. Therefore you may
also emphasise the idea of conscious-unconscious dissociation by saying:
You can go anywhere you like in your conscious mind now... perhaps
somewhere where you would feel very pleasant and relaxed ... and let the
movements happen automatically (or let your unconscious mind do all the work).
220 MEDICAL AND DENTAL HYPNOSIS
If the patient is slow to respond, you may also say:
You may feel a sensation in one of your fingers or thumb - perhaps a tingling -
and when this happens you can help that finger move a little.
The typical movement is a slight, hesitant lifting of the finger or thumb,
often with some flickering tendency. A smooth, brisk movement is likely to
be a deliberate, compliant response, unless the patient has good dissociative
ability. If you suspect compliance, then it is important to repeat the
procedure with a suggestion such as, 'Just let your finger move on its own',
or 'Let your unconscious mind move that finger for you... all on its own'.
When the 'Yes' response has been elicited say, 'Thank you, that's fine.
Now this is your 'Yes' finger' and gently touch it.
Repeat this procedure for 'No' and, if you wish, 'I don't know or I don't
want to say' (or you may have two separate responses for these).
Now, it may be useful to allow the patient to become accustomed to
responding by IMR signalling. You can ask questions of a factual nature
requiring the answer 'Yes' or 'No', as illustrated above with Chevreul's
pendulum. Again, it is up to you to choose whether to address 'the unconscious
mind' or 'the back part of the mind' or to put the questions directly
to the patient. Before embarking on this say:
Now, I want to ask you (or the unconscious mind, etc.) some questions (about
e.g. Mary). If you are (or 'If Mary's unconscious mind is') willing to do this you
(or it) can signal with the 'Yes' finger and if not, with the 'No' finger.
If the answer is 'Yes', say 'Thank you. Now I'd like to ask ...' and
continue as with Chevreul's pendulum above. If the patient withholds permission,
then this probably indicates anxieties about the method, concerns
about what it may reveal, and so on, and these can be explored by normal
discussion.
Our experience and that of our colleagues appear to suggest that usable
responses may be elicited in around 75% of patients, so you have to be
prepared to move on to something else if your patient is not proving
responsive to this method.
Applications of the IMR signalling procedure
IMR signals may be used to augment other hypnotic and non-hypnotic
therapeutic procedures and we shall refer to their use in other chapters. For
the moment, let us summarise their major applications.
The main application of IMR signalling is as an exploratory technique in
Psychodynamically orientated therapy. The therapist is endeavouring to
establish if, for example, it is going to be useful for patients to review any
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 221
memories of events that may still have a bearing on their presenting problems.
Thus the techniques may be a useful prelude to a revivification or
age-regression procedure. We shall present various age-regression methods
later that are augmented by IMR signals. For the moment, please bear in
mind that regression methods are not just for recalling difficult memories;
often we wish patients to recall a time when they were confident, happy,
healthy, and so on.
Similarly, IMR signals may be used to explore whether there are any
unresolved feelings or emotional conflicts that need to be addressed and
which may underlie the presenting problem. For example, the patient's
symptoms may be tension headaches and the therapist may suspect that
these are related to interpersonal stresses in the patient's life that she is
not fully acknowledging and needs to deal with. So one might ask if
the headaches are caused in any way by any difficult feelings or emotions.
If a 'Yes' response is given, then one might ask, 'Is it an anxious feeling?';
'Is it an angry feeling?', etc. If further affirmative responses are elicited,
one could ask, for example, 'Is this anger to do with any member of your
family?'
Ultimately you are probably going to ask patients if it would be acceptable
for them to think more about the material that is being explored and
one can ask for permission through the IMR signals. If one is using the
model of the unconscious mind, one might ask, 'Is it OK for Mary's conscious
mind to become aware of all this now?' Thus we can use IMR signals
to enable patients to indicate permission to proceed, or to indicate that they
are not yet ready for the next step.
Some writers use the term 'IMR signal' to cover any movement that the
patient is instructed to make in order to communicate with the hypnotist,
for example to indicate when she is ready for some medical or dental
procedure to commence. There may be occasions when it is useful for
permission to be given in an unconscious manner, but unless this is so it is
better not to use the term IMR to designate such a signal.
Another adjunctive use of IMR signals is 'communicating with parts'.
If one is working with this metaphor, one might, for example, say to a
patient suffering from bulimia, 'Is it OK for me to speak to the part of Debby
that wants to keep eating?' One can then engage in a further dialogue, first
continuing to use IMR signals, and then gradually encouraging the patient
to communicate by speaking. We shall see later that we can use IMR signals
in a similar way for exploring whether there are any problems with changing
in the desired way. For example, we can ask the patient to imagine
having overcome the presenting problem and then ask the question 'Is
there any part that finds the change difficult to cope with?' Some therapists,
notably those of an Ericksonian persuasion, ask to communicate with
'resourceful' parts, for example 'the part of you that is assertive in your job'
or 'the creative part of you'.
222 MEDICAL AND DENTAL HYPNOSIS
Always bear in mind that this working model of 'parts' is only a
metaphor. Used as such, it may provide a very useful means for facilitating
the processes of inner communication and communication with the therapist
that we have described in the previous chapters. Problems arise when
the 'parts' are reined, that is given a literal status. This is one of the avenues
whereby clients are coached in the role of the patient with multiple personality
disorder.
Let us consider this important point further. At some stage of this discussion,
readers have probably wondered what advantage there may be in
obtaining the information in this convoluted way, if one could more easily
ask the patient for the information in the normal face-to-face manner.
Indeed, one would only use these methods if one had reason to believe that
they would elicit more useful material than normal methods.
One fact readers are probably able to appreciate is how much control
these methods give to the patient and therefore how useful they may be
when broaching very sensitive and distressing material. Indeed, it is possible
to undertake useful therapeutic work even when the patient has not
disclosed to the therapist significant material that has been evoked during
the session. For example, Raj, a teenager with secondary nocturnal enuresis
(seen by MH) was adamant that he could think of no reason or causes for
his bedwetting, yet gave a 'Yes' IMR response when the relevant question
was put to him. A 'No' IMR signal was given to the question 'Is it OK for
you to talk to me about this?' but he gave an affirmative response when
asked to think of possible ways of dealing with these matters other than by
wetting his bed. Thus, perhaps (we can't be sure) he was able to acknowledge
and contemplate that his problem might be connected to other events
in his life, by just registering this with a tiny flicker of his finger.
A rational working model for the therapeutic utility of
IMR signals
There are several problems with the IMR signalling procedure that need to
be addressed before we can advocate its use in therapy. The major problem
is the lack of a good theoretical rationale. It is by no means unacceptable to
inform patients that their unconscious mind, or the back part of their mind,
can communicate information about their problems which is not available
to their conscious mind. However, this can only be construed in metaphorical
terms (i.e. it is as if such is the case). We have already declared ourselves
against this idea of the unconscious mind in literal terms.
Another problem is the temptation of the therapist, and even the patient,
to overvalue the IMR responses. This probably arises from the notion that
they are 'messages from the unconscious mind' and are therefore more
truthful than 'conscious' replies to the therapist's questions. There may be
times when this is so but there is no reason to suppose that this is always the
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 223
case. Unfortunately there is little systematic research exploring the nature
of 1MR signals.
Undue credulity on the therapist's part renders the procedure particularly
vulnerable to a tendency about which we have already warned readers,
namely that ideas and practices are liable to be extended into areas beyond
their range of validity and applicability. Hence, some practitioners almost
invariably use IMR-signalling methods regardless of the patient's problem,
on the assumption that the unconscious mind always knows the cause of
and means of solving the problem.
Perhaps an alternative working model for the therapeutic use of IMR
signalling, one that might be developed as more acceptable than a simple
model of 'the unconscious mind', can be based on the two-stage model of
unconscious-conscious communication developed in Chapter 18. We can
do this by drawing on two sets of ideas.
First, verbal communication allows a range of replies to a question
requiring an affirmative or negative response - for example, 'No', '1 don't
think so', 'I'm not sure', 'Possibly', 'I think so' and 'Yes'. An avoidant defensive
mind-set would bias the responses allowed by shifting each one
towards one end of the negative-affirmative continuum. For example:
Therapist Are you aware of any memories that may still be troubling you
now?
Patient No, I can't think of any at all.
Or:
Therapist Do you think that you have now come to terms with this?
Patient Yes, definitely.
Or:
Therapist Are you angry about this now?
Patient Not at all.
However, we have a much wider repertoire of responses in non-verbal
modalities- for example, body posture, head movements, facial expressions,
autonomic activity (e.g. pallor and blushing) and vocal tone. These responses
tend to be analogue in nature rather than discrete; for example, one can blush
anywhere from very slightly to an extreme degree. So when we ask someone
a question, say 'Are you feeling OK?', the non-verbal response (e.g. facial
expression and voice quality) may be much more telling and convincing than
the verbal answer ('Yes', 'Not too bad', 'Not really', etc.).
Indeed, sometimes there is a direct conflict between the verbal and the
non-verbal response. Someone might ask us, 'Do you like my new outfit?'
Our verbal response may be 'Yes' but our non-verbal language is, unfortunately,
communicating something rather different.
224 MEDICAL AND DENTAL HYPNOSIS
Importantly, our non-verbal communications and the messages they are
conveying vary in the level at which they are expressed in our consciousness
(and in that of the person observing us). On occasions, typified by the
last-mentioned example, we are usually all too aware that our body
language and vocal expression are giving the game away and the answer
they and we are communicating is a definite 'No!' Sometimes, however,
someone asks us a question and our conscious reply is conveyed verbally
while, at a below-conscious level, our non-verbal communication may be
something different. 'You are not angry with me are you?' a friend may ask
us. 'Not at all!' comes back our answer, genuinely expressed, at a clearly
conscious level. But something in our gesture, facial expression, voice tone,
etc. may be registering, 'Well, actually, I am a bit; and, at the same time, I am
also a little anxious about being angry because you might then be angry
with me; and I am feeling a little guilty because I was brought up to believe
that it is usually me who is at fault; and I am also a little sad that our friendship
has hit a bad patch, as I vaguely recall In the distant past more than one
occasion when 1 lost a friend because we argued over such a little thing
What it is to be human! All of this may be registered by the non-verbal
behaviour yet the cognitive activity represented by these statements may be
hardly expressed at a conscious level.
It requires much conscious effort to bias our non-verbal communications
in the way that was earlier described for verbal communication. (For this
reason, it is important always to attend to a patient's non-verbal responses
in a session of therapy.)
It may be, therefore, that what we are attempting to do when setting up
IMR signals is to harness the patient's non-verbal communication system
by nominating a particular response, namely a slight finger movement, to
convey the reply to our question. Note that the reply, rather than in
analogue form, is now encoded in terms of a limited number of discrete
values - 'Yes', 'No', 'I don't know' and 'I don't want to say'.
This does not, however, explain how the index responses can be nominated
by the hypnotist. One possibility is that when one sets up IMR signals
one is giving the patient the opportunity to take less responsibility for the
answers given. In fact, some patients deny being aware of what the finger
responses are; this may be because they have the facility to dissociate, that
is to displace from consciousness both the awareness of the intention of
raising the finger and the kinaesthetic feedback of its position and movement.
Whatever the case, the response is, in a manner of speaking, 'happening
somewhere else'. Thus, we have a response method that is less
sensitive to defensive biasing than the normal channel of verbal communication.
As such, it has the potential (i) to facilitate the conscious expression
of cognitive activity not presently in this form or denied access to
consciousness, and (ii) to facilitate communication by the patient of information
that he or she finds difficult to convey by the usual verbal means.
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 225
IMR signalling, however, should not be construed as a revelation of 'the
truth'. It simply allows the therapist and patient more leeway to explore various
possibilities. Hence patients who give a 'Yes' signal in reply to a question
they have previously given an oral reply of 'No', are not now 'confessing the
truth'. They are simply indicating 'OK, I am willing to explore that possibility'.
It is worth mentioning that ideomotor responding accounts for the
messages elicited by the ouija board ('Yes' or 'No') and other methods that
supposedly spell out messages from the spirit world. It is also the explanation
for facilitated communication (Biklen 1992), a procedure whereby
autistic children and those with learning difficulties are seemingly able to
use a keyboard to tap out fluent messages on a VDU display, even without
having previously learned to write, so long as their hand is supported by a
facilitator. Research has suggested that the information communicated
actually comes from the facilitator (Mulick et al 1993). Ideomotor responding
is likely to be the basis of many dowsing practices. As in many claims of
psychic abilities (and, incidentally, unorthodox healing practices), the magnitude
of the abilities claimed for dowsing has diminished exponentially
with more stringently controlled scientific investigation (Enright 1999).
Final thoughts on ideomotor signalling
We mention all of these things in order to encourage readers to adopt the
appropriate degree of caution and discretion in their approach to the technique
of IMR signalling. We know of highly regarded clinicians who never
use this procedure. However, IMR signalling is a method that we would
wish to keep in the armamentarium of techniques at the disposal of the
practitioner of clinical hypnosis. The reason for this is that many sensible,
competent and experienced therapists find it extremely useful, even though
we suspect that many are overcommitted to it through misplaced credulity.
It seems then that in the absence of any guidance from controlled investigations,
readers must decide from their own experience what the value of this
procedure is in their work.
THE SENSORY-FOCUSING METHOD
The theoretical rationale for this method can be understood from the
foregoing discussion and that of the previous chapter. In Chapter 6, we
described a very useful preliminary to hypnotic induction that we termed
'sensory focusing'. Patients close their eyes and spend some time observing
their 'inner experiences' (as opposed to external stimuli). After some time,
they are asked to comment on anything particular that they notice. By way
of introduction to this, one can say:
Your body communicates to you by different feelings. A particular feeling might
tell you that you are hungry and that you want something to eat: another feeling
226 MEDICAL AND DENTAL HYPNOSIS
may be telling you that you are thirsty and need to drink; another feeling might
be telling you that you are tired and you need to rest, or that you are full of
energy and want to do things. Just observe what your body is telling you now.
When clients are asked if they notice anything in particular, the most
common response is that they feel very relaxed, and then you can proceed
with the induction. Sometimes clients may report tension somewhere - say
in the neck, head or chest - flickering of the eyelids, restlessness of the legs,
and so on. Ask clients to focus on that feeling and say:
Just let it be there. Maybe it will change in some way, become more noticeable
or less noticeable, spread or diminish, or change to some other kind of feeling.
Just notice what happens.
After some moments, you might venture the question:
Do you understand what the tension (specified) is about? Can you make any
sense of it?
Very often clients may say that it is to do with the situation they are in;
they may say, 'I'm a bit apprehensive as I have never been hypnotised
before'. Perhaps one can reassure them here that this is quite natural and
they will find that as the induction proceeds, they will be able to relax and
feel completely safe.
Sometimes it is important to explore the tension further. For example, the
reply to the last question may be, 'Well [ think it's because we were talking
earlier about my mother and I am still feeling a bit upset about this'. The
therapist can then encourage clients to keep thinking about that and to say
a little bit more about the feeling.
Sometimes clients may have some tension somewhere but cannot make
any sense out of it. One can say:
Sometimes we notice that our body is telling us we are tense, but we don't
understand the message. Just keep in touch with that feeling and see what happens.
It is important to note that when using this method, the therapist is not
intending to alleviate the feelings in any way. Therefore, the therapist must
proceed very carefully and not subject clients to any undue distress; if it is
the first session of hypnosis, there is a risk that the therapist may push
clients too far and they will not return for the next session.
The key sequence of instructions is as follows:
Keep focusing on the feeling.
Just observe what happens.
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 227
Can you make any sense out of that feeling?
Is it an angry/sad/anxious/etc. feeling?
If, for example, clients say it is an angry feeling, then ask:
Did you have that anger with you when you came today, or has it come on since
you arrived?
Does your anger make any sense to you?
Is it a familiar feeling? Have you had it before?
If clients talk about, for example, angry feelings concerning their parents,
it is useful to encourage them to focus on a particular memory. Therefore
one might say:
Is there any particular memory that is coming to mind now as you are talking
about this?
Case example
Maria, a 30-year-old woman, had a lifelong problem of claustrophobia, a fear of being in
the house alone and fear of the dark. This problem had become worse in recent years,
probably owing to marital conflict, her husband having left her for another woman. The
therapist (MH) planned several sessions of relaxation, desensitisation and anxiety management
training. At her first session of hypnosis, he asked her to close her eyes and to
focus inwardly, in the manner described earlier. He then noticed that her face bore a
troubled expression and he asked her what feelings she noticed. She reported a tense
feeling in her eyes and some flickering of the eyelids. The therapist asked her to focus
on these feelings and see what happened. Gradually, the flickering of the eyelids
increased and some tears were noticeable.
The therapist asked the client to continue to focus on this and then asked her what
feeling she noticed. She replied that she was feeling very sad. Again the therapist asked
her to stay with this feeling, and more tears were noticeable. He then asked her if she
understood her sadness and she replied that she felt very guilty that she was taking up
the therapist's time when he probably had patients with more serious problems. Rather
than reassure her that this was not the case, the therapist asked her to keep thinking
about this. He then asked her if this was a familiar feeling; was it one that she recognised?
The patient replied, 'Yes, I could never go to my mother with my problems; she
never wanted to know and she made me feel guilty when I did'. The therapist then
encouraged her to bring to mind any particular memories of when this happened and, in
ways that are to be discussed later, helped her with the distress that these memories
were still causing her. (The practice of selecting a salient memory to work on was advocated
in Ch. 12 as a means of helping people with very difficult feelings.)
Having done this work with this patient, the therapist proceeded with the plan of using
behavioural methods to help her with her claustrophobia. It may well be that the
exploratory work done initially helped her have a more profound response to hypnosis, as
otherwise her guilt and unease at the attention she was receiving may have inhibited this.
The sensory-focusing method illustrates that it is more effective to start
with physical feelings, then move up a stage to the affect associated with
228 MEDICAL AND DENTAL HYPNOSIS
them, and then the cognitive content, rather than the other way round. For
example, the therapist may initially ask the above client how she got on
with her mother when she was a child. She may say, 'Fine', or even 'Well
she was rather distant and I could never go to her with my problems'.
However, when answering the question, she does not experience the full
nature of her relationship with her mother and the very sad feelings around
this. (This is of course essential from an adaptive point of view; life would
be intolerable if every single time we recalled something we reacted with
the associated affect.)
The following is a second case illustration with a patient (seen by MH)
who had difficulty closing her eyes. As in the above example, the material
elicited related to the client-therapist transference, but this is not always
the case. Again we caution readers to be very careful and sensitive in using
these methods.
Case example
A woman in her early 30s was referred because of her panic attacks experienced in confined
places such as her church and restaurants. She seemed to quickly develop a
dependency on her therapy; after the first session, she was literally having nightmares
about arriving and finding the therapist's room empty. As in Maria's case, the plan was
to use behavioural methods and in the first session of hypnosis, the sensory-focusing
method was introduced.
Immediately the client opened her eyes and said, 'I don't want to do this'. However, the
therapist encouraged her to 'stay with the feeling' and after several attempts she was
able to keep her eyes closed. She was then asked what was happening and she
seemed to be experiencing some tension. She then said that she was very conscious
that the therapist was looking at her while she had her eyes closed and she opened
them again. The therapist then asked her to close her eyes and to keep thinking that he
was looking at her. This she did with obvious discomfort and began to cry.
Further encouragement revealed that she thought the therapist was looking at her in
a critical way. The next question was 'Is this a feeling that you have experienced before?'
She immediately said, 'Yes' and began crying more and she became very distressed.
She then revealed that her husband was always criticising her and looking for things that
were wrong with her. She said that he had a habit of coming into the room and staring
at her so that she would have to ask him what was wrong. Some time was spent on this
and eventually the patient was able to say how relaxed she felt and she had no desire to
open her eyes. The 'safe place' deepening method was used and on alerting, the patient
commented on how she felt very calm and indeed she appeared to be rather amnesic
for the hypnotic procedures used. When she returned the next week, she commented
that for the rest of that day she felt like she had taken a tranquilliser',
It should be noted that during the assessment of this patient, when asked
how she felt about her husband, she said, 'He's wonderful' and declared
how much she loved him, and no doubt these were genuine expressions. As
in the previous case, this method, by first encouraging the patient to
become more aware of the non-verbal, out-of-conscious responses, then
building up to the affect, then the content, enabled her first to focus more
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 229
fully on her relationship with her husband, and second to communicate this
information to the therapist. This was, in fact, a prelude to more disclosures
about how she felt about her husband.
Readers may discern how the above sensory-focusing method corresponds
with the two-stage model, 'unconscious-to-conscious, consciousto-
overt expression', outlined in Chapter 18, whereby activity not immediately
expressed in conscious form is assisted in becoming so and then may be
overtly communicated to the therapist; then the process of resolution can
take place, as will be discussed later.
Stanton (1992) has described a similar method, which he terms the 'diagnostic
trance'.
AGE REGRESSION
In Chapter 12, we described ways in which it may be useful to ask a patient
to relive in imagination a significant memory. Age regression is really a special
case of this and involves the reliving (or revivification) in imagination of
memories from an earlier developmental period of one's life. It is said that
true hypnotic age regression occurs when the observed responses do not
occur with waking regression (see Nash 1987). However, there is a problem
of definition in distinguishing 'waking' from 'hypnotic regression' and
Hilgard (1986) reports that highly susceptible subjects regress without the
benefit of a hypnotic induction.
In age regression, the subject, to a greater or lesser degree, dissociates,
experiencing the imagined events as very realistic yet remaining able to
respond to questions and instructions appropriate to the non-regressed
state and the context (e.g. 'Now I would like you to come back to the present
time'). We also noted in Chapter 4 the occurrence of 'trance logic' in
some highly susceptible subjects.
Sometimes, spontaneously or under the instruction of the hypnotist,
subjects dissociate in the sense of observing themselves as a child (rather
than being themselves in the situation). Sometimes this may be construed as
a protective device against distressing emotions and thus can be encouraged
by the therapist by the adoption of one of the appropriate regression
methods described below. Laurence & Perry (1981) have reported that those
subjects who spontaneously retain an observing self tend to be those highly
susceptible individuals who show the 'hidden observer' effect (see Ch. 4).
The regressed subject should speak of the events in the present tense, but
this may not be so necessary for therapeutic work. Indeed, in a therapeutic
context, a regression to childish behaviour and manner of speaking does
not necessarily make for better therapy. Given the right expectations, a subject
will do this (e.g. as a volunteer for a demonstration or for entertainment)
but it may be more to do with role-playing skills than the intensity of
the experience. When we age regress subjects, above all we are normally
230 MEDICAL AND DENTAL HYPNOSIS
interested in the emotional component of the experience - what it feels like
to relive that memory. The emotion experienced may be similar to the original
but it will be modified by the maturational process and learning that
have occurred since. So, patients may feel extreme anger when reliving the
memory of their being cruelly treated, but the anger is now that of the adult
rather than the child.
Early reports alleged that dramatic reinstatements of age-appropriate
behaviour, thinking, feeling, physiological and neurological functioning,
and so on, were elicited by age regression. More recent and better-controlled
experiments have refuted these ideas. Nash (1987) reviewed the evidence and
his paper is essential reading for anyone who claims any specialist knowledge
of hypnosis. Variables that must be allowed for in such research include the
person's existing skills and knowledge to effectively role-play, compliancy, the
relaxation response, and, when experimenting on volunteers such as students,
the priming of new subjects by those who have already done the experiment.
We have already discussed the matter of the validity of the content of the
memories elicited by hypnosis (Ch. 18 and Appendix 1). All remembering
(during hypnosis or not) is an activity of construction and is therefore inaccurate
to some degree. Further distortions will occur in the subjects'
account of the memory to the therapist, and the therapist's own understanding
of what patients are saying. Distortions and confabulations will
occur in response to implicit or explicit demands and expectations that the
patient interprets from the context. The more remote the regression, the
greater the tendency to distort and confabulate. For example, a regression
to birth or to the womb, while possibly being an interesting and even
useful fantasy for some people, is not a valid method of accessing anything
the patient experienced at the time.
The conduct of a session of age regression
Most people are capable of replaying in imagination an event from their past.
Hypnotic procedures will facilitate this. It is important to ask permission
from the subject or patient to 'go back in time and look at some important
memories' and whatever procedure is adopted, the therapist should secure
the patient's consent to proceed at each stage, using normal or IMR signals.
A brief induction and deepening routine of the first kind (Ch. 6) is often sufficient,
ending up with an imagery method (e.g. the 'safe place' technique).
Patients will 'go deeper' as they become more involved in the experience.
A safety device can be the instruction that whenever patients need to,
they can leave the memory and go back to their safe place. One can make
use of the 'hidden observer' (or ego state) idea as follows:
Whenever I place my hand on your shoulder like this (demonstrated), you will
immediately be the 'adult you' again and the 'adult you' will be able to talk
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 231
to me about what is going on. Then, when I let go of your shoulder like this
(demonstrated), you will be back as the 'child you'. This will only happen while
you are having hypnosis with me.
Once regressed, initial oral commentary by patients may be difficult
(e.g. because of the relaxed articulatory muscles) and they may become
temporarily more alert again. As the experience develops, commentating
by patients may facilitate their experience.
The therapist's interaction should be appropriate to the regressed age of
the patient, who should be gently encouraged to speak in the present tense.
The first question is often 'How old are you?'; then 'What do you like to be
called?' It may help the patient to 'set the scene' by reference to factual
information, say by asking, 'Who do you live with?'; 'Do you go to school?;
and 'Can you tell me your teacher's name?' As the patient's narrative
unfolds, the therapist should generally use open-ended questions
(e.g. 'What's happening now?'; 'Where are you now?' and 'Who is with
you?') but at times can encourage greater involvement by asking for details
from different sensory modalities, such as, 'Can you see mummy?'; 'What
is mummy wearing?'; 'Can you smell the cooking?'; 'What does Teddy feel
like as you hold him?'; 'What is Daddy saying?'; 'How does your ice cream
taste?' Encourage the patient to linger on good experiences; these may be
anchored, say by a squeeze of the thumb and forefinger, and the easy
retrieval of those good feelings may be suggested. Sometimes in therapy
one can ask, 'What would you like to do now?' and this may be acted out in
fantasy.
If patients become upset, you do not normally immediately bring them
out of experience, although you may remind them of their 'safe place'.
(Sometimes you may want to insist on this.) Follow the guidelines in
Chapter 6.
Before de-regressing say, 'Is it all right to leave that memory now?' The
therapist can then change to a more adult tone and say, 'Are you ready to
come back to the present time? ... OK, take all the time you need,... coming
back into the present ...etc.'. (You could do this using the 'safe place' as a
first step.) Say that the patient need only recall as much of the session as
needed, just as with a dream. Remind the patient of the present date, time
and place and say, 'Tell me when you are right back in the present'. Then
alert in the usual way. Discuss with patients anything they feel is important
and ensure they are fully debriefed.
Age regression may be contraindicated for the deeply or suicidally
depressed person; depressed people have easier access to bad memories,
and re-experiencing these may lower their mood even further. Paradoxically,
reliving a good memory sometimes has the same effect ('I'll never be
able to feel like that again') so while this suggestion can be beneficial, great
care must be taken to avoid an adverse reaction.
232 MEDICAL AND DENTAL HYPNOSIS
Some patients think they must be regressed to overcome their problems,
but ultimately the solutions lie in their present life. The manoeuvre must be
part of a proper plan with some aim at resolving any traumatic kinds of
memory if such are elicited. Plenty of time must be allowed in the session
for this eventuality.
Methods of age regression
These are some of the common methods used.
Open-ended method
Say, for example:
In the unconscious (or deep) part of your mind you have many memories stored
away, some of them good, some not so good, some clear and vivid, some faded
and patchy. Some of them may be relevant to how you are feeling today, in your
present life. Just allow yourself to drift back in time without really trying and see
what the unconscious (deep) part of your mind comes up with. It might be a
clear memory or something vague. Take all the time you want and when you are
there just let me know (head-nod or finger signal).
Regression to a target age
You can elaborate on the above suggestions by, for example, specifying a
particular age. A variant is to count down from the patient's present age to
the target age and, as you are doing this, suggest that the patient is going
back in time, becoming a year younger with each count. You may also suggest
that as the patient is going back in time:
Your body is getting smaller and smaller. You are feeling like a little boy again.
When you reach the age of (say 6), you will think like a child, act like a child, talk
like a child ... and so on.
Using ideomotor signalling
Establish IMR signals (at least for the message 'Yes'). Then say that you are
going to count down from the person's age and as you are counting, the
person is getting younger and younger... etc. When you reach the age at
which some important memory occurs that is relevant to his or her problems,
the 'Yes' finger will automatically lift. (You will have to count back
slowly.)
A variant of this is to exclude the suggestions for regression at first and
to run back through all the years, noting which ones are associated with a
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 233
signal. (This is sometimes called 'the diagnostic scan'.) Then you regress the
person to each of the ages. (Remember that there may have been more than
one incident at a given age.) Some therapists also count back up again in the
same way and then regress the patient to the ages at which an 1MR signal
was obtained when descending and ascending.
Another variant is to first establish by IMR signal if there is a memory that
it is important to review now. Then establish at what age this was; this maybe
short-circuited by such questions as 'Was it at or before the age of 20?', etc.
Arm-lowering method
With the arm in the raised position (catalepsy may or may not have been suggested),
say that as the arm is getting heavier and coming down, so patients
are drifting back in time to the target age, date or relevant incident. Patients
will not be there until the arm has come to settle on their lap. The advantage
of this method is that it allows patients to proceed at their own pace.
The affect bridge or somatic bridge method
This is a useful method described by John Watkins (1971) and may be
the preferred choice when a significant somatic component or wellcircumscribed
affect is expressed - for example, self-consciousness, panic or
psychosomatic problem. However, it is very direct and may provoke an
immediate abreaction. The physical response, feeling or affect, is used as a
bridge to the cognitive content of the memory, in a manner not dissimilar to
the sensory-focusing method described earlier. Remember at each stage to
ask permission from the patient.
1. Elicit the relevant affect or somatic experience by asking the patient to
relive in imagination a recent memory when this experience occurred.
2. Instruct the patient to let go of the content of the memory and focus on
the full affect or physical feelings.
3. Ask the patient to increase the intensity of the affect or somatic
experience, for example by a factor of 2 . . . 3 ... 5... etc. (There is no need
to do this if the experience is already quite strong.)
4. Suggest (with the patient's permission) that the patient is going back in
time, taking these feelings along too (using, if desired, the image of a
bridge, shrouded in mist, etc.) to the first time these feelings were
experienced.
5. Resolve the memory (see later).
6. Check if there are any earlier (or later) memories.
7. Now return to the recent memory that was first elicited and ensure that
the patient now feels better about it in some important way (e.g. that he
or she can now cope with the same situation).
234 MEDICAL AND DENTAL HYPNOSIS
Screen methods
These methods are useful with patients who have extremely traumatic
memories. They purposely aim to protect patients from the emotional experience,
which would otherwise be so severe that they may be at risk from
being further traumatised or would block recall altogether. It is suggested
to patients that they are in a safe place, viewing the memory as one would
a video recording, and they can turn the recording off, switch channels, or
control the image in some other way (e.g. blurring the focus or moving the
screen further away).
As these procedures are especially useful for patients with posttraumatic
stress disorder, they will be presented in further detail when we
cover that topic later in this book (Ch. 30).
The confusion technique
This was briefly described in Chapter 10 and is considered by some as being
useful with patients who are not susceptible to direct methods.
Miscellaneous methods
Therapists are at liberty to construct their own methods. Some methods identify
the year first, then the month and then the date by the use of suitable
imagery. For example, patients may be asked to imagine going down a
corridor passing doors, the number on each door being calendar years
(in descending order - e.g. 2001, 2000, 1999, 1998, etc.). It is suggested that
when they reach a year in which something occurred of significance to their
problems, the door will open up to another corridor in which each of 12 doors
has the name of a month written on it. Again, the door bearing the month of
the year during which the important event happened will open to reveal a
corridor of doors numbered by the days of the month (1,2,3, etc.). When they
reach the door corresponding to the date of the event, this will open. When
they are ready, they are to enter and to relive the memory in question.
There is a similar method to this in which patients imagine being in a
library; the shelves have years on them, the books on each shelf months,
and the chapters dates. One could also use the idea of a video library if one
were using a screen technique.
Applications of age regression or revivification
Age regression (and revivification generally) may be used as a procedure in
psychodynamic, behaviour and cognitive therapy (see later chapters).
Common reasons for using the technique are as follows:
1. You may wish to elicit further information about a particular event
that the patient experienced. For example, in cognitive-behavioural
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 235
therapy you may be asking questions such as 'What are you feeling
emotionally at this point?'; 'Where in your body are you experiencing
that?'; and 'What thoughts are you having at this point?'
2. You may wish to help the patient access positive feelings and
resources, as in the 'clenched fist' procedure (Ch. 12) and in certain
desensitisation methods for counter-conditioning anxiety (see Ch. 20).
3. You may wish to help the patient re-experience, re-interpret or
reconstruct a significant memory in a more adaptive way, or imagine
more effective coping. This application was discussed in Chapter 12
and will be further explored later in this chapter.
AGE PROGRESSION
We saw in Chapter 12 that it is sometimes useful to ask patients to imagine
themselves at some future point in time. The actual time may be specified
(e.g. 'exactly 1 year from now', 'next Christmas', 'on your holidays next
summer', or '5 years from now'). Alternatively, you may wish to specify
certain key landmarks (e.g. 'Imagine yourself in the future when you no
longer have this problem', or 'when you have reached your target weight',
or 'when you have lost just 13 kg (2stone)'). It is sometimes interesting to
ascertain from patients how long they imagine it will be before they have
overcome their problem.
As with age regression, patients may need time to mentally 'set the
scene', so initially their commentary may be more of a factual nature
(e.g. 'Let's see. I'll be 45 and probably have been promoted to senior level.
The children will have left home - that will feel very strange...').
As patients 'get into the part', they will become more aware of feelings
associated with changes that they foresee in their life. As before, gently
encourage patients to speak in the present tense and frame your questions
accordingly ('What are you doing now?', etc.).
Methods of age progression
Methods of age progression are quite straightforward. Usually a simple
instruction, as illustrated in the above examples, is usually sufficient. As
always, ask patients' permission at each stage and ask them to signal when
they are ready to describe their experience. If you wish, you may use some
method of counting the years up, interspersed with suggestions of moving
ahead in time. Another method is arm-lowering, described above for age
regression. Lift the patient's arm into the raised position and suggest that as
the arm is getting heavier and coming down, the patient is moving forward
in time and that the arm will come to rest on the lap when the target date is
reached. Another method is to use the image of a crystal ball. The patient
imagines gazing into it and it is suggested that gradually a picture will
236 MEDICAL AND DENTAL HYPNOSIS
come into focus of the patient in (say) 5 years' time. A screen technique may
also be used. With such a method, at some point you can suggest that
the patient steps into the screen and 'becomes the future' rather than just
observes what is happening.
Applications of age progression
As with age regression, age progression may be used as a procedure within
a range of different types of therapy.
We discussed future rehearsal in Chapter 12 within a cognitivebehavioural
framework and we shall describe the use of anticipated benefits
of changing in Chapter 20. In fact, encouraging patients to keep in mind
these benefits may be a useful way of maintaining their motivation, particularly
when treatment inevitably means confronting anxieties and difficulties
that they have habitually avoided.
In both cognitive-behavioural and psychodynamic approaches, one can
age progress to a landmark in therapy (partial or complete resolution of the
problem - e.g. complete cessation of smoking) and then, using IMR signals
if preferred, ask if there are any problems about changing that need to be
addressed. This may be done by reference to 'parts' of the person (e.g. 'Is
there any part of you that is having difficulty with this change?').
Case example
Sally, who had problems of bulimia and obesity, was age progressed by one of us (MH)
to the point at which she had achieved her target weight. Using IMR signals and the idea
of 'parts', she indicated that she felt very vulnerable. She related this to a fear of being
hurt, and her experience of having an extramarital affair in her early 20s, as a result of
which she became pregnant and had a termination. The man concerned stopped seeing
her as soon as she became pregnant, and because she was unable to tell her husband
or anyone else what had happened, she had to deal with the termination entirely
on her own. Of course, she was able to recall all of these events before coming to therapy,
but the age-progression procedure helped her become more aware of how much
her experience of these events was still affecting her.
Age progression is a very useful procedure whether you are adopting
a psychodynamic, cognitive-behavioural or humanistic approach. Useful
clinical papers on age progression are Frederick & Phillips (1992), Phillips &
Frederick (1992), Torem (1992) and Van Dyck (1988).
RESOLVING DIFFICULT MEMORIES
In previous chapters, we have stressed that whenever one is using a therapeutic
technique, one should always have in mind its purpose and rationale
with regard to the patient's problems and the broader therapeutic
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 237
approach that one is adopting. In Chapter 15, we showed how this is
addressed with reference to the concept of the working model. From this
standpoint, let us give some further consideration to why one should ask a
patient to relive in imagination the memory of an event that was particularly
distressing.
Let us first 'play the devil's advocate' and protest at the very idea of
encouraging patients to relive an unhappy memory when very often they
are already distressed enough about current aspects of their life. This is a
serious question and whatever answer we give should be qualified with the
caveat that the reliving of an upsetting memory should only ever be undertaken
with discretion and sensitivity and with a clear understanding of
how it may ultimately benefit the patient. If such advice is not heeded, then
the outcome may simply be a more distressed and, in some instances, a
re-traumatised patient. (We do acknowledge that occasionally the memory
of an unpleasant event and the distress associated with it are unexpectedly
evoked in therapy.)
This applies even to patients whose main presenting problem is their
inability to come to terms with painful experiences in their childhood, such
as physical, sexual and emotional abuse. Therapy with these patients will be
very much centred around the talking over of the experiences and the ventilation
of emotion by the patient, the principal role of the therapist being to
communicate warmth, empathy and unconditional support in the traditional
client-centred manner. We have already (Chs 16 and 18) outlined a
working model for the rationale of this approach, namely the reciprocal twostage
process of 'unconscious-to-conscious, conscious-to-overt expression'.
Of course, therapists adopting a behavioural, cognitive or gestalt
approach may incorporate into therapy their own techniques aimed at facilitating
this process. Likewise, the practitioner of hypnosis may incorporate,
hypnotic procedures such as regression. But techniques such as these
should only be applied after carefully considering how they will assist the
therapeutic process and balancing this against any risks such as an unproductive
session in which the patient is caused further distress. It is therefore
important that this work is client-led, hence the usefulness of techniques
such as IMR signalling and even the simple regular act of asking the client's
permission. Ultimately, these kinds of decisions can only be made by those
therapists who have proper training and experience in psychotherapy and
it is not within the scope of this book to equip those who have not had this
with the required expertise.
Let us also remind readers that we do not advocate the habitual use of
regression purposely to locate the cause of the problem in some repressed
traumatic memory (see Ch. 18). It is true that there are published case illustrations
in which this appears to have happened. However, as we argued in
Chapter 15, clinical anecdotes do not provide reliable support for a theory
or working model.
238 MEDICAL AND DENTAL HYPNOSIS
Encouraging ventilation of feelings
The reliving of some memories will be associated with an abreaction, that is
the expression of intense emotion (fear, sadness, anger, guilt, etc.). As we
stated earlier, sometimes the feelings will be those appropriate to the incident
but the child will not have been able to express them at the time.
Sometimes they were expressed but in isolation of any acceptance, understanding
or comfort. No-one was around or the child was made to believe
that he or she was not supposed to feel this way. Very often the emotions
expressed are directly linked to the memory, but in reality they will be the
emotions of the adult patient reacting to the memory, and these may sometimes
be very different from the original feelings.
Sometimes it is useful for patients to express their feelings about what
happened, in imagination to, say, the person who was causing the distress
or anger at the time. This is similar to the 'empty chair' techniques
described in Chapter 16.
Very often, the ventilation of emotion is all that is required. Some practitioners
consider that this 'release' of emotion is in itself therapeutic. One
way of understanding this (an explanation that is commonly offered in
everyday life) is a 'hydraulic model', whereby emotional pressure builds
up and needs to be released. Certainly people do seem to suppress their
emotions, only to occasionally 'explode' (particularly with anger or sadness)
as though the pressure is too much to bear. However, we regard this
only as a metaphor with a limited sphere of usefulness.
The reason why simple ventilation of feeling can be therapeutic may be
partly understood in terms of the already discussed process of enhanced
(unconscious-to-conscious) self-awareness. it is not uncommon, even in
everyday life, for people to say, 'I didn't realise how angry (sad, etc.) 1 felt
about this'. A change in self-perception may also occur. Whereas previously
patients may have considered themselves as 'somebody who never cries
(gets angry, etc.)', now they consider themselves as able to express their
emotions with no adverse consequences.
Very important, however, is the fact that much therapeutic work is
achieved through the patient's sharing the emotional experience with the
therapist. The role of the therapist is simply to be a 'good parent', to offer
support and empathy, and to allow the full expression of whatever feelings
are evoked. We also discussed this in Chapter 6.
In addition, there are various procedures that one can take patients
through in imagination to assist them in coming to a satisfactory resolution
if this goes beyond the simple expression of emotion.
Telescoping trauma and too-late comfort
This procedure was described by Karle (1988) and is useful when the traumatic
incident recalled was actually resolved satisfactorily, but it is not
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 239
resolved in memory. That is, the patient's memory is, as it were, frozen at
the moment of maximum distress and despair. This aspect of the memory
predominates and continues to cause distress to the patient. It is as though
it has become dissociated from that part of the memory that is associated
with feelings of relief, safety and reassurance. For example, Karle (1988)
describes how this technique may be used with patients who have bad
memories of being left in hospital as children. Typically, patients recall the
time when as children they were taken to hospital by their parents. The parents
left them on the ward and went home, leaving them feeling that they
had been completely abandoned by their parents. In fact, the parents
returned later at visiting time, yet when patients recall the incident now, it
is clear that they are still suffering from the distress of the sense of being
abandoned. The technique involves taking patients to the point approaching
maximum distress and then immediately fast-forwarding to the point at
which relief is at hand. This is done several times in order to reinforce the
association. (One could use an anchor here for each part of the memory to
facilitate the procedure.) It is important that this procedure is continued
until patients signal that the memory no longer causes them distress.
Case example
This method was used with Eva, a patient one of the authors (MH) saw. She suffered from
a form of claustrophobia, which caused her to feel anxious in any situation where she felt
that she 'had no choice'. For example, she was very anxious on buses because as soon
as the bus would set off she would feel that she now had no choice but to stay on it. This
gave her a sense of feeling trapped. She came to one appointment and described how
that week she had visited the dentist and was informed that she would have to come back
and have some fillings done and this would require a local anaesthetic. Up until then, she
had never been afraid of the dentist, but then she started to dwell on the idea of having a
local anaesthetic and this caused her to feel anxious. Her explanation was that once the
anaesthetic had taken effect, she would have no choice about its being there.
This incident was used in the affect bridge procedure and the memory was elicited of her
brother's locking her in a wardrobe when she was a little girl. (Apparently, he did this kind
of thing on a number of occasions.) She was absolutely terrified and had a feeling that she
was going to be left there for ever. However, it was not long before her mother heard her,
opened the wardrobe, hugged her and reassured her that she was safe. The telescoping
trauma and too late comfort' technique was used satisfactorily, pairing the point where she
believed she was trapped for ever with her mother's appearance and comforting her. The
success of this manoeuvre was then checked by asking her to imagine being at her future
dental appointment and having a local anaesthetic. She actually started to lick her lips and,
when asked, said she could feel the anaesthetic in her gums, but she was able to signal
that she felt fine about this. Unfortunately, she defaulted on all further appointments so it is
not known if. in reality, she went through with her dental treatment satisfactorily.
Counselling the 'child'
Another method is to counsel the patient during the regression as
one would if the incident were really happening in the here and now. For
240 MEDICAL AND DENTAL HYPNOSIS
example, Smith (1979) describes his treatment of a lady with spider phobia
whom he regressed to the first time she could remember being afraid of a
spider. She was in her bedroom at the time and she panicked. The therapist
took her through the incident again, this time counselling the 'child' about
how the spider was, in reality, a very tiny creature and was afraid of her.
(One could, when using this procedure, encourage the patient to give
the spider a name.) The child was then encouraged to comfort the spider
and it was suggested that they were now good friends. Further examples
of this use of age regression in therapy for phobias are provided by
Lamb (1985).
Other examples are provided by patients who were sexually abused as
children and were made to feel guilty and ashamed. While reliving this
memory, the therapist may counsel 'the child', reassuring the child that
what happened was not her fault. (An important message to patients who
are haunted by guilt and self-recrimination over some incident is that they
made the best choice available at the time from what they knew.) We shall
see in Chapter 21 that a very useful concept provided by cognitive therapy
is that of the 'cognitive schema'. In our formative years, we acquire certain
biases in thinking about ourselves and our world. A schema is like a theory,
but is less formally structured. Later on in our lives, some schemas may
prove inappropriate and maladaptive, yet we persist in holding onto them.
For example, a person may have a schema that says, 'When people are
angry with me, it is always my fault' or, 'If I get anxious, then I can't cope'.
Schemas are not usually thought of as having formed as a result of just one
incident; rather they evolve as a result of habitual experiences. However,
there may be one or two incidents that, for the person, are emblematic of all
the ways in which he or she acquired that way of thinking. The method of
counselling the 'child self at the time of one of these 'emblematic' memories
can be very useful for helping patients change their maladaptive
schemas, as can the following method.
The use of 'parts' or ego states
One very effective method is to use 'parts' or ego states. A common
approach is to bring 'the child' to the point of despair and then to ask the
adult ego state to 'go back in time', confront the child and give the child all
the comfort and reassurance that she needs in order to cope with this situation
and feel better about it. The adult is also encouraged to embrace the
child and this may be performed overtly in mime. Then the therapist asks
to speak to the child again and asks the child if she feels better and if there
is anything else that she needs in way of help. This can be done verbally or
by IMR signals according to the therapist's own experience and preference.
This process is continued until the child is able to say that she has everything
needed from the adult part to cope with the situation.
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 241
An example of this procedure is given by Karle (1988). The memory
elicited was of sexual abuse by the patient's father at the age of 6. The memory
was one of running to tell her mother who informed her she had a
'filthy mind' and sent her to her room as punishment. The therapist asked
the adult part to 'pick up her child self, cuddle her and give her all the comfort
that she needed and to explain the truth of the situation.
Case example
This procedure was also used by one of the authors (MH) in the case of Selina, a nursery
school teacher, who had a disabling lack of self-confidence. She came to her second
session and described an incident when her husband's friends visited and were
talking about some political issues. She realised that she had insufficient knowledge of
what they were talking about to make any contribution to the conversation and she was
overwhelmed with anxiety in case somebody asked her for her opinion. This incident
was used by the therapist in the affect bridge procedure and. through this, the patient
recalled a memory of her being at school at around the age of 7. She was asked by the
teacher to spell a word and she got it wrong. The teacher called her out in front of the
class and proceeded to rap her knuckles with a ruler. This was a very distressing incident
for the patient to recall.
The therapist then addressed the adult part,' reminding her that she herself was a
teacher now and could understand how terribly distressing it can be for a child to be
treated in this way. She was also reminded how she was able to comfort children who
were upset. Then she was asked to go back in time and come face-to-face with her 'child
self and provide her with all the comfort that she needed. When the child part was able
to acknowledge that she had everything she needed from this, the next stage was to
move forward in time to the incident that had more recently distressed her. The purpose
of this part of the procedure is to make sure that the patient is now able to cope better
with the situation as an adult and if not, one can, for example, do more ego-state work.
This method can be very effective in changing the way people feel in difficult
situations in their present life. In the experience of the authors, the more
emotionally charged the adult-child encounter is, the more effective the
manoeuvre. It is also important that the patient is judged by the therapist to
have sufficient resources (ego strength) such as self-worth, to adopt the comforting
parent role. Thus sometimes one has to wait until the patient has made
sufficient progress in therapy before the procedure may be effectively used.
Further examples of ego-state therapy will be given in later chapters on
specific problems. It is also recommended that readers consult the April
(1993) issue of the American Journal of Clinical Hypnosis (vol 35(4)) which is
devoted to articles on ego-state therapy.
Coping more effectively with the situation
This procedure involves cognitively rehearsing coping with the situation
using whatever one has learned since, including what one has learned from
therapy. This procedure was described in Chapter 12.
242 MEDICAL AND DENTAL HYPNOSIS
Final comments on resolving memories
Sometimes it is not possible to satisfactorily resolve a memory before the end
of a session of therapy. It is important to allow patients time to 'put that
memory away' with the reassurance that they will find a way of resolving
it with their therapist. When this happens, it is important not to leave
the next appointment too far ahead in the future, and to arrange that patients
can contact you before the next session if they feel the need. If one is experienced
in dream suggestion (see later), one could suggest that between now
and the next session patients will have one or more dreams that will help
them to understand the memory and how to come to feel better about it.
Later in the book, we shall consider other approaches that are appropriate
in confronting and resolving memories associated with post-traumatic
stress disorder.
MISCELLANEOUS FANTASY PROCEDURES IN
PSYCHODYNAMIC THERAPY
The procedures presented in this section have two common features. They
each require clients to engage in two acts of construction. First, clients are
given the suggestion that they are to engage in a creative activity - a dream,
fantasy, drawing or a piece of writing - and that the result will have some
important bearing on their problem. Often the material elicited is in symbolic
form. The second act of construction is that clients are to interpret this
material in their own way with reference to their problems.
These and similar procedures are generally understood from a psychodynamic
standpoint. Our own formulation is that both acts of construction
allow the conscious elaboration of cognition and its associated affect as
described in Chapter 18. However, in our experience, the procedures are not
as widely used by practitioners of hypnosis as those that we have so far presented,
and many practitioners do not use them at all. This may be partly
because they lack a good theoretical model that is acceptable to therapists
of a variety of persuasions. Certainly many cognitive-behavioural therapists
would have difficulty accommodating them in their repertoire of techniques.
They also create the expectation that a significant revelation is going to
emerge - for example, a suggested dream or fantasy that will cast new light
on the client's problems. This may cause anxiety in both therapist and client
about the possibility that this will not happen - for example, the client will
not have a dream, or the dream will prove incomprehensible. Finally, these
procedures appear to require from clients a good capacity for absorption,
imaginal involvement and creative thinking, and some authorities would
also emphasise a capacity for dissociation. Not all clients fit this description.
Whatever the case, we advocate that only practitioners who are well
experienced in psychotherapy should use these procedures and they
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 243
should be considered as adjuncts to a broader programme of therapy, to be
introduced according to the therapist's discretion and judgement.
For all of these procedures, the induction and deepening methods outlined
in Chapter 6 (i.e. the first approach to hypnosis) are recommended.
Dream interpretation
Dreams remain a genuine mystery for psychologists and a great deal is
vet to be learned about them. Nearly everybody dreams, although many
people do not remember their dreams. There are various types of dream,
but here we are interested in the vivid, multi-modal experiences that are
associated with rapid-eye-movement (REM) sleep. People tend to have several
episodes of REM sleep during the night and these become longer as the
night progresses. There is some evidence that when people arc deprived of
dreaming, but not sleep generally, they subsequently dream more to compensate.
This suggests that we need to dream. The idea has been around for
some time that dreaming is a way that the brain reprocesses information
that has accumulated during the day and this is of adaptive significance.
Do dreams mean anything?
Are our dreams telling us something? There is a long history of dream
interpretation and some rather extraordinary ideas. Some people consider
that dreams may be portents of future events and thus have a paranormal
status. A famous precedent for this is the interpretation by Joseph of the
dream of the Egyptian Pharaoh described in the Bible. Needless to say we
do not accept these ideas.
Freud himself postulated that dreams are fantasies resulting from a
'relaxing of repression' and hence a representation of unconscious activity
that is threatening to the ego (Freud 1933). The dream is still subject to
censorship, hence the content is in symbolic form, relating to primitive
emotional and sexual themes.
Dreams are certainly bizarre creations and it is probably true to say that
we would find it difficult to consciously construct in the waking state the
dreams that we have at night. They also have an absurdity, realness and
spontaneity that make them different from most waking fantasies.
Although there is no shortage of popular books on dream interpretation,
we see no evidence to support the idea that dreams can be understood in
terms of 'If you dream about X, this means Y' kinds of explanations.
Perhaps the dream itself, then, is random gibberish. This is not dissimilar to
the theory that was put forward in 1917 by Poetzl (see Poetzl 1960), namely
that a dream consists of information that we did not fully attend to during
the day, and consequently need not be of significance. But as an act of construction
by the client's mind, surely the dream should have sortie meaning
244 MEDICAL AND DENTAL HYPNOSIS
of relevance to the client, just as a poem, painting or piece of music says
something about the mind of the person who created it.
We cannot be absolutely sure about this. But perhaps it is not the dream
itself, but how the client interprets the dream that is significantly revealing.
Asking the client to do this may be similar to doing a projective test such as
the Rorschach inkblots or the Thematic Apperception Test (TAT) (Morgan &
Murray 1935). The latter consists of a series of pictures about which the
respondent has to make up a story.
Case example
Eight-year-old Peter was shown (by MH) a TAT picture of a boy sitting alone on the steps
of a wooden house. Peter's interpretation of this was that the boy's real mother had gone
away and he was being looked after by a different mother. He did not like her and he was
sitting waiting for the real mother to return. In reality. Peter had always lived with his
mother, but in the past she had been physically cruel to him and the Child Guidance Unit
was keeping a close eye on them. (Followers of Melanie Klein may wish to interpret
Peter's story in terms of the defence of splitting.)
In recent years, projective tests have been regarded with some disfavour,
and certainly the inkblot tests have not passed muster according to the
stringent requirements of reliability and validity. On the other hand, it does
not strain credulity to consider that projective storytelling may reveal valid
information about a person's inner world, considering how much is commonly
inferred from works of literature and poetry about the workings of
their creator's minds. Hence, even if a dream is nonsense, the client's interpretation
of it may still be of therapeutic value.
A simple method of dream analysis
Sometimes clients come to a session of therapy and spontaneously describe
a dream they recently had that seemed significant in some way. Perhaps the
feeling in the dream was unusually intense or the memory of the dream
keeps recurring. Also, the dream itself may recur. The following is a simple
method that can help clients use the dream as a means to achieve greater
self-awareness along the lines we discussed in Chapter 18.
The first step is always to ask clients what sense they make of the dream.
This may be all you need to do: there is not necessarily a right or wrong
answer. What you should help clients achieve, however, is a simple, parsimonious
interpretation that uses as little of the dream content as possible
and that makes sense to them. What clients initially do is to become hooked
on the specific details of the dream when, according to this method, these
are not necessarily of significance. For example, a client may say, 'I can't
understand why I was driving a Ford, when my car is a Volvo' or 'Why did
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 245
my old school friend Ted pop up in my dream? 1 haven't thought about him
for ages'.
It may be advantageous for clients to go through the dream in imagination,
frame by frame, whilst giving a running commentary. This may elicit further
content and affect, but there is a possibility that if the dream was upsetting,
then the client could re-experience all the original bad feelings. This is unnecessary
for present purposes. Whatever the case, you wish to know from your
clients what is or are the predominant emotion or emotions in the dream.
Case example
Arthur (seen by MH) was a wealthy businessman who was receiving counselling for
stress. Seven years previously, he had served a prison sentence for fraud. Since his
release, he had prospered. He was married with two children and lived in a magnificent
house. When seen for counselling, he reported that he had started to have bad dreams
of his time in prison and being tormented by the prison officers. He would wake up
sweating in a panic
Arthur could not explain why he was having these dreams. One possibility was that he
still had not got over the trauma of his imprisonment, but that did not seem to ring true
with Arthur. Whatever the case, the main emotions in his dream were anger, frustration,
helplessness and some fear.
The next step is to help the client express the theme of the dream in its
most abstract sense, devoid of as much content as possible. This is not
always easy, as clients often have difficulty leaving behind the details. In
Arthur's case, the theme of his dreams was his being trapped and unable to
do anything about it.
You now ask clients to put together the theme and the feelings and ask,
'In what way does this connect with anything that is happening in your life
now?' The 'now' is important.
Case example (continued)
When Arthur was referred for counselling, his business was in trouble, but he knew that
if he kept working, eventually the economic cycle would turn in his favour, his business
would start to pick up again and he would be able to pay off his debts. In the meantime,
he was compelled to work long hours, commute great distances each day, arrive home
exhausted every night, and so on. He saw no way out as he had committed himself to a
huge mortgage, was educating his children privately, and felt obliged to keep his family
in the manner to which they had grown accustomed.
In this example, the meaning of the dream appears so obvious that one is
entitled to ask, 'So what?' In fact, it is not unusual that when one brings
clients to the point where the interpretation of the dream seems so obvious,
246 MEDICAL AND DENTAL HYPNOSIS
it still seems to elude them. One way of thinking about the dream, then, is
that, figuratively speaking, it is drawing clients' attention to something
that they are not fully acknowledging. It is, as it were, a kind of inner communication
that says, 'Please attend to this'. Sometimes, as in Arthur's case,
clients are not able to do much about these matters, but the understanding
and enhanced self-awareness that this kind of simple interpretation of the
dream gives clients can still be very helpful.
Dream suggestion and interpretation using hypnosis
A more elaborate method is to ask clients to go through the dream during
hypnosis and to make the suggestion that they will be able to interpret the
dream in their own way. In this kind of analysis, the content of the dream
assumes greater importance than in the former method. To start with, however,
one can give clients the posthypnotic suggestion that between now
and the next session they will have a dream of significance to their problem.
The mechanisms that may account for why a posthypnotic suggestion
such as this should prove effective, requiring as it does a response that is
not under the control of the subject, have not been adequately explicated.
Degun & Degun (1988) review the experimental evidence that such a
posthypnotic suggestion can be effective, but it does not appear that investigators
have provided adequate controls for such things as baselines and
compliance with the demands of the experimenter.
The following is a procedure used by the British clinical psychologist
Marcia Degun-Mather and described in Degun & Degun (1988). Her
method actually incorporates the possibility that the dream may occur during
the day and may be no more than a sudden, 'out-of-the-blue' thought.
Here, however, we keep to the single suggestion of a night-time dream.
First, one explains in a simple way something of the nature of dreams.
For example, one can say that sometimes we are worried about something
but may shelve it to the back of our mind in favour of everyday routine
activities and distractions. The content of the concerns and worries may
later surface in the form of dreams at night. Dreams are often illogical, and
symbols and other methods of disguise are used.
One can then go on to explain that it has been shown that people can have
dreams during hypnosis (we shall discuss this later) or as a result of
posthypnotic suggestion. Therefore hypnosis can be useful in eliciting a
dream or dreams that may reflect important aspects of the problem that can
be the focus of therapy. It is also necessary to explain that even though one
does not initially understand one's dreams, it is possible to make sense of
them and again hypnosis may be a useful means for helping this.
Do not be put off if clients say they never remember their dreams or indeed
that they do not dream. If they are hypnotisable, the hypnotic suggestions of
recalling dreams seem to work for those who are highly motivated.
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 247
During hypnosis, the posthypnotic suggestion is given as follows:
Between now and your next appointment, you will have a dream which will throw
light on your problems, and how you might overcome them. You will remember
the dream so that you can tell me about it when you come to your next session.
Reassurance is given that once clients are able to perceive and understand
the problem through the medium of the hypnotic dream, they will be
able to solve it in one way or another with the therapist's help. Instruct
clients to have paper and pencil at the bedside to write down the dream.
Encourage them to write down anything and everything that they recall of
their dream, even if it seems like nonsense.
It is often easy to assume that clients understand that dreams take disguised
forms. They frequently do not understand this and think that they
will dream in very concrete and specific terms about their problem, though
this is very seldom the case.
When clients describe the dream do not be deterred by the fact that you
yourself do not understand it. If you feel you do understand it, do not be
tempted to interpret it, as the client's understanding may be quite different
from what you expected.
If clients are unable to understand the dream at the next session, then
hypnosis is again used and suggestions are made that they will go through
the whole dream and be able to elaborate on the meaning. This can be done
by using an imaginary blank screen or theatre stage with the dream projected
onto it. Through relating the dream in more detail, as is often the
case, a further understanding of the dream is possible. Care is taken not to
impose interpretations, though questions can be asked by the therapist.
This then opens the way to making adaptive changes in thinking and
behaviour as discussed in Chapter 18.
Hypnotic dreams and fantasies
Instead of a dream at night, the therapist may suggest that clients have one
during the hypnotic session. The preliminaries and instructions are similar
to above. One can simply say that the dream will begin when clients are
given the signal and they are to signal when the dream has ended. Clients
may commentate on the dream as it is unfolding, but the usual procedure is
to wait until the dream has ended before asking clients to go through the
dream again, in the manner described above, encouraging them to come to
their own understanding.
It is useful to precede the dream suggestion with the safe place or beach
or garden deepening technique. Clients are to imagine being in that place,
lying down, closing the eyes, and having the dream.
A similar technique, originally described by Wolberg (1946), is to suggest
that the fantasy takes place on the stage of a theatre or the screen of a cinema.
248 MEDICAL AND DENTAL HYPNOSIS
Wolberg's theatre visualisation technique
Clients are told to imagine that they are sitting in the stalls at a theatre. They
are to give a signal as soon as they can picture themselves quietly sitting there
looking at the closed curtains, waiting for the performance to begin. They are
told that they can see a woman (or man, in the case of a male client) standing
on the side of the stage, and peeping behind the closed curtains. This woman
can see what is taking place on the stage behind the closed curtains and what
she sees is making her look very frightened or unhappy. Clients signal when
they are ready to have the curtains open and when they do so they can see
what is actually causing the woman to look so unhappy or frightened. As
soon as they can see the play that is occurring on the stage, they are to raise
their hand. As soon as this happens, they are asked to describe the action that
is taking place on stage. They are then encouraged to come to their own
understanding of what the scene means in terms of their problems.
When using this and other techniques described in this chapter, occasionally
the client spontaneously abreacts and this is one reason why the
methods should only be used by experienced psychotherapists.
Clients are then told that they will see the curtains close. A second suggestion
may then be given that the woman at the side of the stage can now
see something happening on stage that is making her look extremely
happy, as if her dearest wishes had been fulfilled. It is suggested that clients
will be wondering what it is that is making this woman feel so happy, and
when they are ready to signal for the curtains to open again, they will be
able to see the action on the stage. As soon as they can see this, they are to
give a signal and to describe exactly what they can see. Again, clients are
encouraged to arrive at their own understanding of this scene.
The jigsaw puzzle visualisation technique
This is similar to the theatre or cinema technique described above. The suggestions
are as follows:
I want you to sit upright in the chair and imagine a small table in front of you. On
that table there are several coloured boxes ... red ... green ... yellow ... and blue.
Each of these contains the pieces of a separate jigsaw puzzle. You will notice that
there is no picture on the lid of the box. Let me know when you can picture this.
That's fine. Now I want you to choose one of those boxes - any colour that
you prefer - and turn out the pieces of the jigsaw puzzle on the table and let me
know when you have done this.
I don't know what picture will eventually emerge and at the moment you
probably do not know yourself, but it will be the picture of a scene or incident
that is closely connected with your present problems. Your unconscious mind
(or the back part of your mind) knows and will help you to fit those pieces of the
jigsaw puzzle together so that we shall be able to see what this picture is.
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 249
Now start fitting the pieces together. You will be able to do so much more
quickly than when you are wide awake. Tell me what you can see as the picture
gradually builds up.
In the above procedure, the kind of picture that is to be produced may be
specified but this is not always necessary. It may be better first to leave the
choice of the picture to clients until they have become familiar with the technique.
Then, if desired, it may be suggested that the picture is one associated
with some difficult feeling or with pleasure, as in the theatre technique.
It may well be that the colour of the box selected is not entirely without
significance. Some therapists believe that when the red box is chosen, it not
infrequently happens that the picture, together with the client's associations
to it, reveals the presence of unacknowledged fears or even aggressive
or sexual conflicts. The green box is often said to be associated with
conflicts in which jealousy (particularly sibling rivalry) plays an important
part, the yellow one with feelings of inadequacy, and the blue box with
conflicts centred around problems of frigidity and lack of feeling. This is
part of the folklore of analytical hypnosis and we are not aware of any
controlled research on the subject.
Some clients will enact the whole process of picking up the pieces of the
puzzle and fitting them together. If, at any stage, clients say they can see
nothing more, they can be told that the picture is not yet complete, and that
as they continue to fit more of the pieces together, they will be able to
describe what else they see.
Clients may begin by describing scenes containing meadows, water, trees
and houses. In that case, it may help to gently ask a question such as 'Can
you see any people or children there?' At some stage, one can ask if the
scene is a familiar one, what clients think is going on, what the people are
doing and thinking, and so on. At this point, clients may start to free associate
to the image, and this may lead to further elaboration and understanding.
Sometimes, however, clients may be reluctant to disclose the
material and it may be better to suggest that there is no need for them to
acquaint you with the content of the picture as long as they take a good look
at it themselves and work out its significance.
Automatic writing and drawing
The technique of automatic writing or drawing is undertaken by placing a
pencil in the client's hand during hypnosis and suggesting that the hand
and arm may behave without any conscious thought or effort on the client's
part. It may be helpful to refer to common everyday examples of when this
occurs. It may then be suggested that the hand will begin to write and
will move along quite automatically so that the client will not be aware of
what is being written. As with the other methods, it is suggested that the
250 MEDICAL AND DENTAL HYPNOSIS
message will help clients understand better their problem and how they
may solve it.
The product of such writing is usually quite different from clients' normal
writing. It is often quite undecipherable. Letters are badly formed,
words run together and sentences are incomplete and fragmented. Whenever
clients are able to open their eyes without becoming fully alert again,
they can be instructed to write the full meaning of the communication
underneath the automatic writing. If they are unable to open the eyes in
this way, they can be given the posthypnotic suggestion that the meaning
of the automatic writing will be quite clear to them after they are alerted.
As usual, it is always best to let clients translate it for themselves.
Rather than write, clients may either be instructed to draw whatever they
like, or themes may be suggested to them by the therapist. In their drawings,
clients may reveal attitudes towards members of their family, their
spouses and children or even the therapist, of which they are not fully
aware. One variation of this is to ask clients to make up a story about their
drawing. Some therapists combine this technique with age regression, the
idea being that clients may be able to more easily express in drawings,
attitudes and feelings that are denied at the 'adult level'.
METHODS FOR CHILDREN AND ADOLESCENTS
All of the methods described in this chapter may be used, with suitable
modifications, with children and adolescents. In addition, the following
two methods have been presented by Benson (1984, 1988). The first is
intended to help children broach problems in their life that may be
addressed by therapy or counselling. The second is a kind of ageprogression
technique that may, as we have described in the earlier section
on age progression, again disclose problems that need to be addressed.
The 'parcels' fantasy
This procedure is preceded by the 'tidying a desk' fantasy described in
Chapter 14. It also uses the metaphor of 'the subconscious mind' described
in that chapter.
Have you given that desk a good sort out? Have you found any particular
problems in there that need tackling today?
If 'No' is signalled, move on to next stage of therapy. If 'Yes', then proceed
as follows:
Imagine now that those problems are made up into a paper parcel.... Each layer
on that parcel is a different problem. Each layer has a big label on it On one
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 251
side of the label, it tells you what the problem is and on the other side of the label
your subconscious mind gives you some ideas what can be done to sort it out.
The questions below are a guideline only and have to be adapted to the
particular situation in which this method is being used.
Can you see the label on the top layer? Can you read what it says?
If 'No' is signalled, ask for a few clues:
Now, you don't have to tell me anything if you don't want to but if you do want
to talk you can do ... quite easily and naturally.... It won't stop you relaxing. ...
Do you want to tell me what the problem is?
If this is disclosed, continue:
Now, turn the label over and see what suggestions there are for getting rid of
that problem.
One then proceeds with further therapy, counselling and advice as
appropriate. Then continue:
Do you think you can get rid of that problem now?
If the answer is in the negative, then ask if this is possible at some future
date. If 'never', then suggest that the child will learn to cope with it and will
learn not to get upset by it.
Get rid of it, then throw it away on a bonfire and signal 'Yes' when it's gone.
Work through each problem layer until the parcel has disappeared.
The crystal ball and maze fantasies
Now I want you to imagine that you've got a crystal ball in front of you. The
sort of crystal ball that fortune-tellers have to look into the future. You can't
really see what's going to happen in the future but I'd like you to look into that
crystal ball and get a good clear picture of how you would like your future to
turn out ... when all this trouble is over and things have settled down.... What
you'll be doing ... where you'll be living ... what sort of person you would like to
be. Signal 'Yes' when you've got a good clear picture of your future.
Await the signal, then continue:
Now imagine that the future you want for yourself is on the other side of a
maze ... maybe the sort of maze you get in a comic where you have to trace a
252 MEDICAL AND DENTAL HYPNOSIS
path with a pencil ... or maybe a real maze with paths and hedges. You have to
find your way through the maze from where you are now to where you would
like to be on the other side. It might not be easy; you might have to go over a
few obstacles; you might have to go a long way round; or you might have to start
again. But there is a way through, so you see if you can find it. If you get through
without my help, signal 'Yes' to let me know. If you get really stuck somewhere,
signal 'No' to let me know you need some help to get through.
If 'No' is signalled, counsel and advise as appropriate, then try again.
That's very good. You're really making plans for your future now. You know what
you want and you know how you're going to get there!
Modern metaphors
As we indicated in Chapter 14, readers may wish to use more contemporary
material for these kinds of fantasies. For example, in both of the above
cases, computer games could be substituted, the crystal ball now being a
VDU controlled by the child, likewise the maze, or the child may travel in a
time-machine or space-ship.
REFERENCES
Benson C 1984 Short-term hypnotherapy with delinquent and acting-out adolescents. British
Journal of Experimental and Clinical Hypnosis 1: 19-28
Benson C 1988 Hypnosis with difficult adolescents and children. In: Heap M (ed) Hypnosis:
Current clinical, experimental and forensic practices. Croom Helm, London, ch 29, p 314
Biklen D 1992 Typing to talk: Facilitated communication. American Journal of Speech and
Language Pathology January: 15-17, 21-22
Cheek D B, LeCron L M 1968 Clinical hypnotherapy. Grune and Stratton, New York
Degun M D, Degun G 1988 The use of hypnotic dream suggestion in psychotherapy. In:
Heap M (ed) Hypnosis: Current clinical, experimental and forensic practices.
Croom Helm, London, ch 21, p 221
Enright J T 1999 Testing dowsing: The failure of the Munich experiments. Skeptical Enquirer
23: 39-46
Frederick C, Phillips M 1992 The use of hypnotic age progressions as interventions with
acute psychosomatic conditions. American Journal of Clinical Hypnosis 35: 89-98
Freud S 1933 New introductory lectures on psycho-analysis. Lecture XXIX: Revision of the
theory of dreams Hogarth Press and The Institute of Psycho-analysis, London
Hilgard E R 1986 Divided consciousness: Multiple controls in human thought and action.
Wiley, New York
Karle H 1988 Hypnosis in analytical psychotherapy In: Heap M (ed) Hypnosis: Current
clinical, experimental and forensic practices. Croom Helm, London, ch 20, p 208
Kirsch I, Lynn S J 1997 Hypnotic involuntariness and the automaticity of everyday life.
American Journal of Clinical Hypnosis 40: 329-348
Lamb V D 1985 Hypnotically-induced deconditioning: Reconstruction of memories in the
treatment of phobias. American Journal of Clinical Hypnosis 28: 56-62
Laurence J-R, Perry C 1981 The 'hidden observer' phenomenon in hypnosis: Some additional
findings. Journal of Abnormal Psychology 90: 334-344
19: HYPNOTIC PROCEDURES IN PSYCHODYNAMIC THERAPY 253
Morgan C D, Murray H A 1935 A method for investigating fantasies: The Thematic
Apperception Test. American Medical Association 34: 289-294
Mulick J A, Jacobson ] W, Kobe F H 1993 Anguished silence and helping hands: Autism and
facilitated communication. Skeptical Enquirer 17: 270-280
Nash M 1987 What, if anything, is regressed about hypnotic age regression? A review of the
empirical literature. Psychological Bulletin 102:42-52
Phillips M, Frederick C 1992 The use of hypnotic age progression as prognostic,
ego-strengthening and integrating technique. American Journal of Clinical Hypnosis 35:
99-108
Poetzl O 1960 The relationship between experimentally induced dream images and indirect
vision. Monograph 7. Psychological Issues 2: 41120
Smith C S 1979 Age regression and cognitive restructuring in the treatment of a spider
phobia: A brief case report. Bulletin of the British Society of Experimental and Clinical
Hypnosis 2: 19-20
Stanton H 1992 Brief therapy and the diagnostic trance: T'hree case studies. Contemporary
Hypnosis 9: 130-135
Torem M S 1992 'Back from the future': a powerful age-progression technique. American
Journal of Clinical Hypnosis 35: 81-88
Van Dyck R 1988 Future oriented hypnotic imagery: Description of a method. Hypnos:
Swedish Journal for Hypnosis in Psychotherapy and Psychosomatic Disorders 15: 60-67
Watkins J 1971 The affect bridge: A hypnoanalytic and counter-conditioning technique.
International Journal of Clinical and Experimental Hypnosis 19: 21-27
Wolberg L R 1946 Hypnoanalysis. Heinemann, London
An eclectic approach to
psychotherapy augmented
by hypnosis
Chapter contents
Introduction 283
The aims and rationale of eclectic psychotherapy 283
A framework for the application of hypnosis to eclectic psychotherapy 284
INTRODUCTION
We have now reached the end of our overview of the common psychotherapeutic
approaches. Readers may already be experienced in and committed
to one particular school of therapy, in which case their use of hypnotherapeutic
procedures will be constrained by that therapeutic approach. Other
readers may be eclectic and work at different levels, using a number of
different therapeutic approaches. In that case, they may not be 'experts' in
any particular approach.
If you do work eclectically, then you need a framework for determining
what approach and what level to focus on with any given patient at any
given time. Therapy may lose impact if it does not follow a theme or themes
in a coherent manner. Let us now address this matter.
THE AIMS AND RATIONALE OF ECLECTIC
PSYCHOTHERAPY
From our discussions in the previous chapter of the common aspects of
the various systems and schools of psychotherapy we can suggest that one
rationale for psychotherapy is that patients and clients are restricted to
maladaptive ways of feeling, thinking and behaving in certain aspects of
their lives (which may be general, as in depression, or specific, as in certain
phobias and bad habits). Therapy therefore aims to enable people, where
possible, to be less restricted in the above ways and thus to have more
choices available to them. This may be achieved in the following overlapping
ways:
1. By the use of methods of learning and conditioning, therapy may
directly change the way patients or clients respond physiologically
and behaviourally to those situations in which they are limited to
283
284 MEDICAL AND DENTAL HYPNOSIS
maladaptive ways of responding. (Examples: desensitisation,
aversion therapy, assertiveness training and anxiety management
training.)
2. Therapy may identify, explore, and challenge dysfunctional patterns
of thinking that patients and clients habitually adopt concerning
themselves, their problems, and their world, and offer the means for
acquiring more realistic and adaptive ways of thinking. (Examples:
cognitive therapy, including cognitive restructuring and education.)
3. Therapy may encourage, in an adaptive way, confrontation with
aspects of the patients' or clients' internal and external world that they
are avoiding. (Examples: psychoanalysis, cognitive-behavioural therapy,
non-directive psychotherapy.)
Hypnosis may be used in all of the above, with a view to enhancing
effectiveness.
A FRAMEWORK FOR THE APPLICATION OF HYPNOSIS
TO ECLECTIC PSYCHOTHERAPY
It is customary to say that hypnotic procedures are best considered as
adjuncts to therapy. But what do we mean by this? One interpretation is
that the hypnotic procedures that we have described form but one component
of the sum total of therapy undertaken with the patient. Yet we
shall see that sometimes - for example, for smoking cessation and psychosomatic
problems - the entire treatment may consist of one or more sessions
of therapy in which hypnotic procedures are used throughout. In other
words, therapy starts with the preparation and induction and ends with
alerting the patient (and may include self-hypnosis).
Another interpretation is that the adjunctive component is the hypnotic
induction and deepening routine. We could still administer all the procedures
without this, but we assume that it augments the therapy, rendering it
more effective.
Yet another interpretation is based on the argument that for a procedure
to be defined as 'hypnotic', it has to discriminate amongst subjects of high
and low hypnotic susceptibility. Within any session of therapeutic hypnosis,
there will be techniques that do this and others that do not. The more
the outcome of the therapy depends on the former, the more it may be
validly described as 'hypnotherapy'. Hence, one might use the description
'adjunctive' in that sense.
Whatever interpretation readers favour, it is certainly the case that
'hypnotic' procedures can provide the cement for the structure of an eclectic
programme of therapy, allowing one to move fluently between the different
levels - cognitive, behavioural, emotional and physiological. The framework
for this is provided by Figure 21.1 (p. 279). Using this framework, the
22: ECLECTIC APPROACH TO PSYCHOTHERAPY AND HYPNOSIS 285
plan for a course of hypnotically augmented therapy can proceed as
follows:
1. Assessment
Prior to any therapy you will, as is usual in psychological treatment,
conduct a careful assessment of the patient and the presenting problems.
This will enable you to make a formulation of the problem (i.e. what it is and
why the patient has this problem) and to establish a working model of how
your therapy generally, and hypnosis particularly, may alleviate the problem.
We have described above a general working model and this can
form the basis of the particular working model that you adopt for your
patient. This allows you to plan the procedures and techniques you are
going to use.
2. Preparation and preliminaries
Your working model will influence the way you prepare the patient for
hypnosis and your choice of approach as described in Chapters 6 and 7,
which then determines the kinds of preliminaries you undertake with the
patient.
3. Induction and deepening
Your choice of induction and deepening methods will again be determined
by your working model and your choice of approach to hypnosis.
You are now ready to begin the main part of your hypnotherapeutic work.
The following is a rough guide to the various stages that you might
work through. Please note, however, that a course of therapy does not
necessarily run along smooth lines and no session will include all of these
stages. As we have already stated, age regression (as opposed to the recall
of more recent memories) is to be used with discretion as often it proves
unnecessary to review remote memories.
4. Cognitive rehearsal of problem situations
The aim at this stage is to identify salient triggers, namely external and
internal stimuli, such as palpitations in the case of panic disorder, and the
cognitions associated with them.
5. Regression
From the above stage, one may explore with the patient (by normal enquiry
or IMR signalling) if there are any important memories related to the above
problem situation. If so, one can use regression by the affect bridge to elicit
286 MEDICAL AND DENTAL HYPNOSIS
these early relevant memories. Some of these may encapsulate the schemas
that developed in formative years - for example, family problems, times of
feeling rejected, traumas, physical and sexual abuse, and bullying at school.
These may be resolved by counselling the 'child', the use of adult-child ego
state therapy, and so on (see Ch. 19).
6. Miscellaneous therapeutic methods
One may then introduce hypnotic or non-hypnotic procedures specifically
for changing the maladaptive ways of reacting to the problem situations.
7. Cognitive rehearsal of previous situations
One can then suggest cognitive rehearsal of coping with previous situations
using these new ways of behaving and thinking introduced at Stage 6.
Occasionally this work may elicit additional areas of difficulty that can be
addressed by further schema-focused work using regression, thus looping
back to Stage 5.
8. Age progression or future rehearsal
Age progression may be used for cognitively rehearsing coping with future
problem situations, and imagining life without the presenting problem.
Areas of difficulty may be identified (perhaps by using 1MR signalling).
This may indicate the necessity for further work requiring the therapist to
loop back to Stages 5 or 6.
9. Metaphors and anecdotes
10. Posthypnotic suggestions
11. Ego-strengthening
12. Instructions for self-hypnosis
13. Alerting
14. Instructions for assignments between sessions
These may relate to confronting problem situations.
Other psychodynamic methods may be incorporated into this
framework - for example, dream suggestion may be used when the therapy
seems to 'get stuck'.
This plan covers a wide range of problems but it is not appropriate for all
of them. The skilled practitioner will judge when it may be fruitful to use
hypnosis and when this is likely to be unnecessary or unhelpful.
Risks, precautions and
contraindications
Chapter contents
Introduction 287
General 287
The importance of a thorough assessment 288
Regression and abreaction 289
Considerations when using group hypnosis 289
Some problems that require particular consideration and care 289
INTRODUCTION
The next section of this book is devoted to the application of hypnosis to
specific problems and disorders in medicine, psychiatry and psychotherapy.
The reader will discern that hypnosis has a very wide range of application
and it is difficult to identify in categorical terms any condition or disorder
for which hypnosis should never be used. We shall however attempt to provide
some guidance for assisting therapists in their decision whether or not
to use hypnosis for any given problem. First, we shall discuss potential
adverse effects, and some precautions and contraindications. The final section
of this book is also very relevant to these matters.
GENERAL
It is our opinion that hypnosis is a comparatively safe procedure and that
where adverse reactions have occurred these are usually not due to some
special property of hypnosis, but are explicable in terms of more general
effects. However, the potential for adverse effects should be taken very seriously
and we shall now explore these more fully.
Does hypnosis itself, regardless of the context in which it is practised,
have some special property or properties that are inherently harmful in
themselves? Some people, usually those who support a strong 'trance'
model of hypnosis, consider that there are (Gruzelier 2000). These writers
contend that hypnosis is an altered state of consciousness involving certain
neurophysiological changes that mean that the subject is vulnerable both
to beneficial and to harmful influences. Thus some researchers claim to
287
288 MEDICAL AND DENTAL HYPNOSIS
have demonstrated that following a session of neutral hypnosis or a routine
non-clinical procedure such as a hypnotic susceptibility scale, certain individuals
have unpleasant after-effects including headaches, panicky feelings
and confusion (Crawford et al 1982, Page & Handley 1990). Some people
consider that subjects may be at risk if they are 'not taken out of their trance
properly' or if the suggestions given during hypnosis 'are not properly cancelled'.
Barber (1999) has suggested there is a small minority of individuals
who experience some degree of confusion for a period after hypnosis; these
are probably what others would term as having high dissociative capacity,
although Barber prefers the expression 'amnesia prone'.
Some authorities believe that these side effects are no different than those
that have been reported for other relaxation and imaginative procedures
such as meditation and guided fantasy (Brentar & Lynn 1989, Coe & Ryken
1979, Conn 1972, Lynn et al 1996, Lynn et al 2000).
Whether or not there are properties intrinsic to hypnosis that may have
adverse consequences, anyone using hypnosis, for whatever purpose, can
expect that very occasionally subjects will become upset for reasons that are
difficult to predict. Sometimes this may be simply because individuals have
anxieties about 'being out of control', even though they may have been
assured that during hypnosis subjects are still 'in control'. In Chapter 6, we
outlined ways in which the hypnotist should respond to unexpected signs
of distress. Also, very occasionally we have heard of individuals who, having
been hypnotised, then worry that something unusual has happened to
them, for example because their mind has been controlled. We stress that
these incidents seem to be rare but may arise because hypnosis does have
'spooky' connotations associated with mind control and there are a few
individuals who ruminate about this afterwards. It is likely that such individuals
have problems of psychological adjustment that require psychiatric
help if their worries surrounding hypnosis prove persistent.
Whatever the case, many reported ill-effects caused by hypnosis are
likely to arise from the way it has been used. These issues are discussed further
in Chapter 33.
THE IMPORTANCE OF A THOROUGH ASSESSMENT
When hypnosis is being used to treat medical problems and pain, it is
essential that patients have had a thorough medical examination, that their
medical condition is appropriately monitored, and that they continue to
receive the relevant medical treatment. Similarly, where patients are being
treated for a psychiatric disorder (e.g. depression, anxiety disorder or eating
disorder), then therapy should be informed by a thorough mental state
examination, and patients should have access to the recommended psychiatric
treatment (although we acknowledge that some patients choose not to
take medication).
23: RISKS, PRECAUTIONS AND CONTRAINDICATIONS 289
REGRESSION AND ABREACTION
On several occasions in this book, we caution that the use of direct methods
of regression and the deliberate provocation of abreaction should be undertaken
only with a careful assessment of how these procedures are intended
to help clients or patients with their presenting problems. The therapist
engaged in such procedures should have undertaken professional training
and qualifications in the psychological understanding and treatment of
people with emotional disorders, independent of training and qualifications
in hypnosis.
In fact, modern practice appears to favour procedures that involve more
gradual exposure to traumatic memories, thus avoiding severe abreactions.
There are risks of further traumatising the patient with post-traumatic
stress if an abreaction is not satisfactorily resolved. Readers are referred to
Putnam (1992) for a thorough discussion of this subject. Similar concerns
apply to the technique of flooding in imagination.
All practitioners using revivification and regression methods must be
aware of the risks that memories thus elicited may be unreliable or false.
This matter has been more thoroughly discussed in Chapter 18 and guidelines
are given in the Appendix of this book.
CONSIDERATIONS WHEN USING GROUP HYPNOSIS
When carrying out group hypnosis, it is not recommended that any regression
work be attempted. This is because of the risk of distress, as occasionally
sad memories are stirred up even when the instruction is to bring to mind a
happy memory. Because there are other people present, individuals may
have no opportunity to talk over their experience with the therapist. It is
true that some hypnotic susceptibility scales that are used in groups do
have a regression item, but this is short and well structured. Even so,
whether the context is the laboratory or the clinic, when conducting group
hypnosis, it is recommended that the hypnotist is available for a sufficient
length of time after the session to talk over any difficulties that any members
of the group may have experienced during the session. Some practitioners
are able to bring along a colleague or colleagues for this purpose.
SOME PROBLEMS THAT REQUIRE PARTICULAR
CONSIDERATION AND CARE
If nothing else, one consequence of using hypnosis inappropriately is that
it may be a waste of time. It is not easy to predict how successful a hypnotherapeutic
approach will prove to be or whether its adjunctive use will
enhance the effectiveness of therapy. One guide is the available research
evidence on what problems and disorders appear to respond to hypnosis.
This literature is reviewed in Chapter 33.
290 MEDICAL AND DENTAL HYPNOSIS
Although hypnosis is commonly used in the treatment of anxiety disorders,
cognitive-behavioural therapists will be mindful of the priority
given in their approach to eliminating avoidance and safety-seeking
behaviours, and encouraging in vivo exposure. The use of hypnosis may
actually delay this process, and the practitioner should be alert to this
possibility. This caveat pertains in particular to therapy for phobias and
obsessive-compulsive disorder.
Contrary to earlier accounts, hypnosis is not contraindicated in the psychological
treatment of depression (see Ch. 31). However, there are now
well-structured cognitive-behavioural treatments of proven efficacy for
the treatment of depressive illness and, as yet, there is insufficient evidence
that hypnotic procedures improve on this. Accordingly therapists treating
depression should satisfy themselves that the inclusion of hypnosis in treatment
has a good chance of improving outcome, and is not simply a waste
of time and effort. Care should be exercised to avoid exacerbating the
depressed mood by, for example, the use of regression procedures that
involve the reliving of unhappy memories. As in non-hypnotic therapy,
suicidal risk should be monitored.
There have been reports in the literature of the adjunctive use of hypnosis
in the treatment of people who have psychotic illnesses or who are
prone to psychotic-like episodes (e.g. borderline personality disorder) by
practitioners who are highly skilled in psychotherapy with these patients.
Without such expertise, this is not advisable; procedures that involve absorption
in imagery and fantasy may further weaken the already tenuous grasp
of reality on the part of such patients. Similarly, involvement in hallucinatory
symptoms may be amplified. Hypnotists may risk their becoming part of
the delusional system of a patient with paranoid schizophrenia, mania or a
delusional state. This does not entirely rule out the use of hypnosis, say, to
assist the dental treatment of an anxious psychotic patient whose illness is
well controlled by medication. In such cases, the dentist should consult the
patient's psychiatrist for advice and guidance.
In the USA, Canada and some other countries, the diagnosis of multiple
personality disorder (MFD) or dissociative identity disorder (DID) is frequently
made with the assistance of hypnotic procedures (see Ch. 18). In
other countries, including the authors' own, the consensus in the mental
health services is that MPD, if it exists at all as a psychiatric disorder, is
extremely rare. The consensus further regards the increasing incidence of
MPD in North America over the last 20 years as an iatrogenic phenomenon,
although it is not disputed that the patients so diagnosed are suffering from
psychiatric disturbances and are in need of treatment. The present authors
strongly discourage the use of hypnotic procedures as a means by which
the diagnosis of MPD or DID is made.
We contend that there is no property specific to hypnosis that has adverse
physical effects. The safeguards for patients with life-threatening conditions
23: RISKS, PRECAUTIONS AND CONTRAINDICATIONS 291
are the same as those for non-hypnotic treatment and should be in place
during a session of hypnosis. For example, any emergency medication such
as asthma inhalers or anti-anginal sprays should be immediately available,
and the practitioner must make it clear that patients may halt the proceedings
at any time to use their medication. Severe abreactions should be
avoided in any patients who are advised against sudden excessive exercise.
Although hypnosis has been shown to be beneficial in the treatment of
asthma, some concern has been expressed about the use of direct symptomcontrol
methods that may reduce the patient's respiratory drive below a
safe level (see Ch. 25).
REFERENCES
Barber T X 1999 A comprehensive three-dimensional theory of hypnosis. In: Kirsch 1,
Capafons A, Cardena-Buelna E, Amigo S (eds) Clinical hypnosis and self-regulation:
Cognitive-behavioural perspectives. American Psychological Association, Washington DC,
ch l , p 21
Brentar J, Lynn S J 1989 'Negative' effects and hypnosis: A critical review. British Journal of
Experimental and Clinical Hypnosis 6: 75-84
Coe W C, Ryken K 1979 Hypnosis and risks to human subjects. American Psychologist
34: 673-681
Conn J H 1972 Is hypnosis really dangerous? International Journal of Clinical and
Experimental Hypnosis 20: 61-79
Crawford H J, Hilgard J R, Macdonald H 1982 Transient experiences following hypnotic
testing and special termination procedures. International Journal of Clinical and
Experimental Hypnosis 26: 117-126
Gruzelier J 2000 A review of the adverse effects of experimental, clinical and stage hypnosis.
Contemporary Hypnosis 17: 163-193
Lynn S J, Martin D f, Frauman D C 1996 Does hypnosis pose special risks for negative effects?
International Journal of Clinical and Experimental Hypnosis 44: 7-19
Lynn S J, Myer E, Mackillop J 2000 The systematic study of negative post-hypnotic effects:
Research hypnosis, clinical hypnosis and stage hypnosis. Contemporary Hypnosis
17:127-131
Page R A, Handley G W 1990 Psychogenic and physiological sequelae to hypnosis: Two case
reports. American Journal of Clinical Hypnosis 32: 250-256
Putnam F W 1992 Using hypnosis for therapeutic abreactions. Psychiatric Medicine 10: 51-65
SECTION 4
The application of hypnosis
to specific medical, dental
and psychological problems
The hypnotic procedures that we have so far described
may be applied to a considerable range of problems
that are encountered in psychotherapeutic, medical and
dental practice. In the present section, we examine
common problems in which hypnosis is considered to
have the potential to play an effective role. In each case
practitioners are urged always to consider, for any
patient and any given problem, what 'working model'
they are adopting. Relevant to this are the assumptions
concerning the purpose of hypnosis, including the
hypnotic induction and deepening procedures, and for
this we return to our earlier distinction of 'suggestion'
and 'trance'. With some problems, such as smoking or
being overweight, the emphasis will be on maximising
responsiveness to suggestion and the expectation of a
successful outcome, and the preparation and induction
will reflect this. For others, such as insomnia, the aim
will be absorption and detachment from the immediate
environment and ongoing concerns. In some cases,
such as psychosomatic problems or pain, the choice
will vary according to circumstances, and sometimes a
combination of approaches is appropriate. In all of the
problems considered in this section, behavioural and
cognitive methods tend to be favoured, but we also
illustrate the advantages of a flexible, eclectic approach
and the usefulness of psychodynamic procedures when
these appear to be indicated.
Hypnosis in dentistry
Chapter contents
Introduction 397
Legal and ethical issues 398
General considerations in treatment 398
The amelioration of discomfort and pain 399
Control of bleeding 400
Bruxism 401
Gagging 401
Temporomandibular joint dysfunction 403
Dental anxiety and dental phobia 404
INTRODUCTION
A famous person once commented that the greatest blessing of technological
progress in the 20th century was the improvement in routine dental
treatments. Indeed, it is only relatively recently that a visit to the dentist
(or whoever took on that role) was inevitably associated with agony
and dread. Not surprisingly, therefore, there is a tradition of using mesmerism
and hypnosis to ameliorate the ordeal. John Elliotson himself (see
Ch. 1) in the 19th century included dental extractions amongst many other
surgical procedures that he carried out solely using mesmeric passes to
effect analgesia.
Even today, despite all the advances, anxiety about going to the dentist is
still very prevalent, and sympathy is automatically offered to anyone who
is due for an appointment. Historical and cultural influences play their
part: in the country where one of the authors (KKA) grew up, it was an
exciting adventure to go to a dentist.
Dental anxiety results in a restless or rigid patient in the dental chair and
this makes the patient feel helpless and often the dentist also. A handful of
such cases in a day is enough to cause more exhaustion and stress than any
dentist would wish for.
One adult in three has moderate-to-severe fear of dental procedures
(British Dental Association 1995) and this problem is very prevalent
amongst children. Genuine dentally phobic people often do not see the dentist
at all. In extreme cases, the result is that the entire mandible sequestrates
owing to osteomyelitis, separating in a single piece.
397
398 MEDICAL AND DENTAL HYPNOSIS
Other problems include gagging. Constant gagging while the dentist is
trying to take an impression means that an unsatisfactory outcome
is inevitable. Indeed, the gagging patient may not be able to wear dentures
at all, however perfectly they have been made, and may keep returning
to the surgery to complain. Also, the treatment of temporomandibular
joint (TMJ) dysfunction can be daunting for the patient as well as the
dentist. Bruxism (habitual grinding of the teeth) is another problem whose
consequences are evident to the dentist.
The use of hypnosis in adults and children can provide some answers
to these problems. As most dentists who use hypnosis acknowledge, it
can make routine dentistry less stressful for the practitioner and can
be extremely rewarding. Equally, hypnosis has a place in emergency
treatment, such as with the patient who presents with an acute dental
abscess.
LEGAL AND ETHICAL ISSUES
The matter of whether it should be made explicit when hypnotic procedures
are being used has been discussed in Chapter 8. Relaxation, imagery and
distraction techniques are commonly used by dentists as and when they
deem them appropriate, and the business of introducing them as 'hypnosis'
interrupts the session and takes up time that dentists may not have allowed
for. We suggested in Chapter 8 that unless techniques such as eye fixation and
arm levitation are used (procedures that are more characteristic of the second
approach to hypnosis), the practitioner is justified in referring to 'relaxation'
or 'imagination'. We are not sure what the position is in countries such as the
USA, where the use of hypnosis may have legal implications.
As always, dental practitioners must only use hypnosis for problems that
are of concern to dental care. It is not unheard of for patients, knowing that
their dentist uses hypnosis, to ask for help with their non-dental problems.
The dentist should resist these requests and encourage these patients to
seek more appropriate help, or refer them to their general medical practitioner,
who will advise them of the most appropriate professional person
to see.
GENERAL CONSIDERATIONS IN TREATMENT
Crucial to easing the patient's anxiety is the creation of an ambience that is
friendly and reassuring. Efforts to achieve this should start with the reception
staff, by their conveying warmth and friendliness when they take
appointments by the telephone, and greeting the patient at the reception
desk in a pleasant manner. This attitude should also be adopted by the
nurse and the dentist. The waiting area can be made less clinical and more
homely. Appropriate pictures, including pictures on the ceiling above the
29: HYPNOSIS IN DENTISTRY 399
dental chair, will help calm patients, especially children. Soft music is
another good idea.
Rapport and trust are enhanced when the patient is given a full explanation,
in non-threatening language, of what is going to happen; undue
surprise or shock is thus avoided. Parents should be allowed to stay with
their children. The instruments which may appear most threatening to very
anxious patients should be kept out of sight if possible.
Putting all those ideas in place will take away the sting of any painful
procedures. They are also important for success in any hypnotic interventions.
The most essential ingredient of any dental procedure, and one that is
most important when hypnosis is used, is some form of signal that the
patient can make to stop the treatment immediately and to discuss any
problems. Without this, patients are likely to hold on to the fear of losing
control. A common misconception of hypnosis is that 'trance takes away
personal control' and patients therefore fear that they are going to be hurt
and can do nothing about it. Losing control is the most significant feature of
dental anxiety or phobia.
Let us now review the common applications of hypnosis in dental practice.
We shall leave the most common application, namely assisting the
anxious patient, until the end.
THE AMELIORATION OF DISCOMFORT AND PAIN
As we stated earlier, dental treatment is all too often still associated in the
public mind with anxiety, discomfort and pain. Yet dentists assert that
nowadays patients overestimate the amount of real pain that is experienced
during routine dental procedures. It seems that the main problem is that
patients anticipate pain. For example, they may think, 'What if the drill
slips and catches a nerve?' On the other hand, some pain is not uncommonly
experienced and it cannot be said that dental treatment can be anything
better than 'uncomfortable'; as patients, we have to lie back with our
mouths wide open, and are therefore unable to communicate with our
'assailant' (the dentist) in the usual way. We are thus rendered passive and
are unable to see where all the action is taking place - namely, in our mouth.
This adds to the sense of uncertainty and apprehension. Many patients also
have more general anxieties relating to medical settings, injections, the
sight of blood, and so on.
Consequently, dentists trained in hypnosis find that simple suggestions
and imagery conducive to calmness and comfort can help ameliorate the
unpleasantness and discomfiture that patients experience to varying
degrees, even when chemical analgesia and anaesthetics are administered
(in which case these techniques may be a prelude to the injection). Some
dentists, in fact, use hypnosis as an adjunct to relative analgesia. With less
anxious patients, suggestions, imagery and distraction techniques may be
400 MEDICAL AND DENTAL HYPNOSIS
administered informally, without a hypnotic induction. With more anxious
patients, and where pain is likely to be significant, formal methods are
required.
For young children, distraction may be the most appropriate ploy. If one
is using guided imagery, one can suggest that patients go to a safe place
where they will enjoy doing something interesting; meanwhile, the dentist
can do all that has to be done and give the reassurance 'nothing will bother
you at all'. (Note the avoidance of the word 'pain' or 'hurt'.)
The popular method of directly suggesting hypnoanalgesia is transference
of glove anaesthesia (see Ch. 25). It is important to test the effectiveness
of the suggestion before transferring the analgesia to the desired area.
Producing glove anaesthesia has the added advantage of demonstrating to
the patient that 'hypnosis works'. When indicated, it is in order to suggest
that the analgesia will continue to give adequate comfort during the postoperative
period, provided that necessary safeguards are also suggested,
such as seeking advice when complications arise.
At the end of the session, always congratulate the patient for the successful
use of hypnosis; this is in itself ego-strengthening and will facilitate
future sessions. If appropriate, teach the patient the whole of the procedure
for self-hypnosis, including the suggestions relating to pain control, but
without the testing of analgesia. If the patient practises this regularly, this
will enable the practitioner to omit the induction, deepening and administration
of analgesia suggestions, and this will speed up future treatment. A
well-practised patient does not even have to go to a practitioner who is
adept at hypnosis.
Patients presenting with any form of dental pain may have similar kinds
of hypnotic interventions to provide instant analgesia, or at least to render
the pain more tolerable for as long as is necessary. It should of course be
ensured that the patient will have proper treatment in due course. On
the other hand, one may proceed with treatment where this is warranted
and if the patient responds well to the suggestion of analgesia. Medical
and dental practitioners report that in their experience, someone who is in
agonising pain and therefore highly anxious, usually proves to be well
motivated and responsive to hypnotic suggestions to help them cope.
Hypnoanalgesia and hypnoanesthesia also have the benefit of producing
no side effects.
CONTROL OF BLEEDING
The literature on hypnosis and the control of bleeding reports mixed
results (Enqvist et al 1995, Hopkins et al 1991). There are also reports
of the successful use of hypnosis in the management of haemophilia
(Dubin & Shapiro 1974, LeBaron & Zeltzer 1984, Lucas 1975, Swirsky-
Sacchetti & Margolis 1986), although not all have obtained positive results
29: HYPNOSIS IN DENTISTRY 401
(Lichstein & Eakin 1985). Dentists who use hypnosis often aver that
bleeding control is easily achieved by direct suggestions of 'no bleeding',
'less bleeding' or 'no need to bleed'. When images of cold and ice are used
to create analgesia, they may also be allied to the suggestion that the blood
vessels are constricting and therefore the loss of blood is reduced.
Posthypnotic suggestion of minimal bleeding during the healing period
may be given, but it is important to include the suggestion of having
sufficient bleeding to form a clot to occupy the socket, thus preventing the
possibility of dry-socket bone infection.
BRUXISM
Jaw clenching and teeth grinding at night are invariably out of a patient's
control. One theory is that bruxism is an expression of pent-up anger and
helplessness (Pierce et al 1995). Whatever the case, as bruxism is an expression
of tension, training the patient in general relaxation using hypnotic
techniques is the first step. This may be followed with suggestions focused
on relaxation around the muscles that move the jaw. Once this feeling of
relaxation is well established there, anchor it with a clenched fist or fists and
give posthypnotic suggestions that whenever the patients clench a fist or
fists, the jaw muscles will become profoundly relaxed. Rehearse the anchoring
method and teach patients, by covert practice, how to use it as a means
of releasing anger and frustration in everyday life (see Ch. 12). Also give
ego-strengthening suggestions relating to self-control. Cognitive rehearsal
is next carried out with the suggestion that the patient is in bed and tension
is building up in the jaw muscles and this automatically makes the patient
want to clench the fist(s). As soon as the patient clenches the fist(s), the
previously anchored relaxation returns to the jaw muscles, displacing the
tension there.
When the patient has repeated the procedure a number of times and
shows confidence in the method, further posthypnotic suggestions are
given that the patient will practise all of this at home before bedtime. A tape
recording may be prepared for this purpose. Being able to control
unwanted negative thoughts and feelings will help the patient fall into a
natural, relaxing sleep.
GAGGING
Reflex gagging may present as anything from a mild form of choking to
violent retching when the palate is simply touched or, for example, during
the taking of impressions. The fauces, base of tongue, palate, uvula and
posterior pharyngeal wall have maximum sensitivity and so form trigger
zones. Certain conditions such as chronic nasal obstruction or sinusitis may
402 MEDICAL AND DENTAL HYPNOSIS
increase the predisposition to gag (Bartlett 1971). Psychological contributions
are represented by conditioned protective reflexes from earlier experiences
or existing stresses and anxieties. Simply the sight, sound and even
the thought that something out of the ordinary is going to enter the mouth
may precipitate gagging.
Helping the patient understand the nature of gagging removes some of
the embarrassment and possibly even some of the anticipatory anxiety.
Hence, hypnosis for eliminating gagging starts with an explanation of
its nature. The reflex action begins with the sensation of touch, either real
or imaginary, in the mouth, especially at the trigger zones. Therefore, in
theory, if those areas are made to feel numb, this should eliminate the reflex
cycle of gagging.
After hypnotic induction and deepening, introduce appropriate egostrengthening
suggestions that create a positive expectation of success.
These are followed by suggestions of relaxation of the throat muscles.
Encourage the patient to breathe slowly and steadily through the nose. This
instruction is useful for patients whose gagging is associated with a fear of
asphyxiation. Now introduce the image of how well the patient will be in
the future when all the treatment has been carried out and, if relevant,
when the patient is able to tolerate the new dentures. Anchor the positive
feelings and the images by the clenched fist method, or with an imagined
word, etc. Rehearse the anchoring and create the positive experience
several times. In the same session or, if time is not available, in the following
session, proceed to produce glove anaesthesia and then transfer this to
the trigger points to make them as numb as required in order to stop the
gagging reflex. The numbness can be created by directly suggesting that
these areas are gradually becoming numb, or that they are experiencing tingling
that leads to numbness. These suggestions may be augmented by
suitable imagery.
Once this is achieved, start with the gradual, step-by-step desensitisation
process in imagination. At every level, and whenever there is any sign that
the reflex is being activated, instruct the patient to use the anchor to reinforce
the feelings of calmness, self-control and confidence in success, and
remind the patient to breathe slowly through the nose. Success at each stage
is fed back to the patient to reinforce continued confidence.
Once the patient is able to go through the procedures confidently
in imagination, progress to the use of real materials, using if necessary
instruments of the smallest size and then gradually increase to normal size.
For example, in the case of intolerance of dentures, one can start with a
small-sized plate or a toothbrush, beginning on the front parts of the tongue
and progressing to the back of the mouth. Instead of instruments, one could
use cotton buds, tongue spatulas or even spoons.
It may not be possible to achieve full competence in one or two
sessions, and therefore it is highly beneficial to bring all these ideas
29: HYPNOSIS IN DENTISTRY 403
together into a self-hypnosis routine for the patient to practise several
times at home.
Case example
With some patients, all the efforts at desensitisation may fail in spite of achieving a good
response to hypnosis itself, and this may indicate some underlying psychological gain
or unacknowledged problems. In such situations, a psychodynamic approach using
hypnosis may reveal unexpected reasons for the difficulty. A middle-aged woman, Nita,
was referred for treatment to one of us (KKA) for severe gagging and failure to have
impressions made. She had the same experience with a toothbrush if it accidentally
touched the back of her mouth. She failed to make progress with the already described
methods of desensitisation. The affect bridge technique (Ch. 19) elicited the memory of
her being sexually abused in the form of forced oral sex by her father. It was then that
she herself began to interpret her smoking as a defence: 'He can't put it in when there
is something burning near my mouth'. The trauma was effectively resolved and so also
the gagging. To the patient's own surprise, she never wanted to smoke again.
Nita's case is an unusual example of what may happen when hypnosis
is used Psychodynamically, but it also highlights the limitations of the
dental practitioner who will not be trained in dealing with such matters.
However, where there is a conditioning experience, it is most likely to be
having something stuck in the throat that causes choking and fear of
asphyxiation or being forced, while feeling sick, to finish up one's food by
parents.
TEMPOROMANDIBULAR JOINT DYSFUNCTION
The nature of TMJ dysfunction is very complex. Structural malfunctions
and diseases are the commonest contributors, but the problem may be more
psychosomatic in nature. The pain or discomfort may be confined to the
joint or joints, but it may spread to anywhere in the facial region, sometimes
resulting in an inability to tolerate dentures. When the usual treatment has
failed, hypnotic techniques, in the form of pain control and relaxation, may
prove effective, or they may be used as an adjunct to traditional treatment.
It is not unusual to find a tender spot on the temporalis muscle, ipsilateral
to the TMJ pain. Relaxation of the muscles of mastication, and pain control
methods described in Chapter 25, especially focused on the 'tender spot',
may be all that is required in many cases.
TMJ dysfunction may have emotional concomitants that require the
assistance of professionals trained in psychological therapies and counselling,
but hypnosis can be an extremely useful adjunctive procedure,
especially when symptom-oriented methods have failed, when it can then
be used Psychodynamically to help the patient acknowledge and resolve
any underlying problems.
404 MEDICAL AND DENTAL HYPNOSIS
Case example
Agnes, a patient of one of the authors (KKA). was a widow in her late 50s, who had
reached the state of being unable to wear dentures without experiencing severe pain
and a very uncomfortable tingling sensation in her face and temporomandibular region.
The problem started as 'discomforting' sensations on the left side of her face when she
was wearing her dentures. Her dentist made some new dentures for her but after several
unsuccessful attempts at wearing them, she was referred to a dental hospital
Despite further treatment, the discomforting sensations turned to pain and tingling
that spread to the inside of her mouth, the TMJ area and the opposite side of her face.
Eventually, she was having pain at times when she was not even wearing the dentures.
She was referred to neurologists for investigative tests but she herself finally came to the
conclusion that there were psychological aspects to her problem, and hypnosis was
offered.
During hypnosis, the affect bridge procedure triggered her expression of grief as she
described the scene of her husband's sudden death, He was lying on the floor when
she walked into the room and his dentures were out of his mouth and 'staring at her'.
She expressed guilt at 'not doing anything to prevent his death'. This was resolved by
counselling. The pain lessened for a while but came back as before, even though she
was expressing more of the grief. She was unable to reveal any more reasons for the
continuation of her grief and of the pain.
A modified form of the dream suggestion technique (Ch. 19) was then introduced in
the hypnosis session. She could accept a working model describing how the normal
sensory input into the brain from the affected parts could be distorted on its way to the
cortical 'cognition centre' by the actions of 'messengers' from some parts of her memory
store, especially memories relating to certain emotional trauma or guilt (see Ch. 28).
Such distortions could change a normal feeling to a feeling of pain.
Once Agnes had accepted this model, it was suggested during hypnosis that an
imaginary agent had been planted in the pathway of the sensory input and this would
recognise the 'messengers'. This agent would identify the nature of their mission and
this would be revealed to her in a dream.
Sure enough, the patient reported a dream about her son, who was showing extreme
anger and throwing things at her. She then broke down with feelings of extreme guilt
because, soon after her husband died, she left the house where they had lived their
entire married life. Now she felt that she had thus abandoned the love that they had for
each other. She was left asking herself how she could have done such an injustice to her
beloved husband.
The solution was at hand, as the therapist, during hypnosis, reassured her that 'Love
is always carried in your heart and it goes with you all the time wherever you go. It does
not live in the bricks and mortar of the house'. This was illustrated to her by the therapist's
own experience of the love for his father that he carries in his heart even though
he now lives thousands of miles away; this love is no less than when he was in his
father's house. Her grief then eased, she completely recovered from the pains, and she
was able to wear her dentures with no problem.
DENTAL ANXIETY AND DENTAL PHOBIA
As we noted at the beginning of this chapter, one in three patients attending
any dental surgery suffers some degree of anxiety to the level of panic.
Hypnosis is an effective tool in helping such patients to undergo dental
procedures with confidence and enabling a dental visit to be a regular
experience for them.
29: HYPNOSIS IN DENTISTRY 405
Depending on the severity of the anxiety, the dentist's use of hypnotic
procedures may be informal (blending in with the dentist's usual patter,
say to distract the patient or to encourage the patient to engage in some
pleasant imagery) to a formal course of therapy, beginning with historytaking
and followed by a programme of desensitisation (see below).
Although hypnosis is often cited as being time-consuming, dentists who
use hypnosis find that patients with moderate degrees of anxiety often
respond well to relatively brief formal induction methods. Severe cases,
notably those who have avoided dental treatment (the true dental phobics),
do, however, require a more structured programme.
If the anxiety is not too severe, the dentist will find that the procedures
we have outlined in earlier chapters - hypnotic induction and deepening
(e.g. the 'safe place' method), suggestions of continuing calmness and
relaxation, ego-strengthening, an anxiety management method such as the
clenched fist procedure, posthypnotic suggestions, and self-hypnosis to
rehearse dental appointments - collectively lend themselves well to the
task of helping the dentally anxious patient. For more severe problems, the
following programme of treatment may be undertaken.
Therapy starts with history-taking and assessment, and this includes
establishing a hierarchy of the anxiety-provoking situations and stimuli
(see Ch. 20). These may be the smell of anaesthetic, the feel of the probe in
the mouth, the sound of the drill as it is turned on, and so on. Standardised
dental anxiety scales may be used (Humphries et al 1995). Special attention
is given to the kinds of physical symptoms associated with anxiety, as these
are targeted in the desensitisation procedure.
When the patient is ready, one can go through the preparation and
preliminaries outlined in Chapters 5 and 6 (the first approach to hypnosis).
Then, take the patient through a sequence of induction and deepening
procedures to establish a state of deep relaxation. We suggest including the
'safe place' method as this is good for distraction purposes and for calming
patients if their anxiety level becomes too high. Suggestions of total body
relaxation are repeated along with ego-strengthening suggestions appropriate
to the patient's goals. Relaxation and resourcefulness (drawn from
previous achievements) are then anchored, for example using the clenched
fist procedure, or using an Image or a word chosen by the patient. Age progression
may also be used to create images of having a better life, when the
patient is cured of the fear and is the proud owner of a good set of teeth. The
patient is instructed to practise regularly the whole routine in self-hypnosis.
When patients reach proficiency in creating a sense of calmness and
relaxation using their anchors, they may be taken through the desensitisation
programme (as above) step-by-step in imagination. Patients are asked
to dwell on each fear-provoking situation, to experience the fear, and then
to follow with the anchoring method for reinstating a sense of relaxation,
calmness and self-control. Once they are able to remain calm with that
406 MEDICAL AND DENTAL HYPNOSIS
image, with their permission one proceeds to the next stage in the hierarchy,
and so on. It is important to be aware that even though al] of this is done
in imagination, the physical and emotional stress to the patient can be
extreme. Therefore, patients should be able to signal when they wish to stop
the image and, for example, switch to their safe place. Hand or finger
signals to indicate 'Yes' or 'No' or 'Stop immediately' are the most efficient
way of communicating during hypnosis.
Once the patient has gained confidence in the imaginary rehearsal of the
full treatment session, one can begin the actual dental treatment, proceeding
step-by-step with plenty of reassurance and feedback for every sign of
success (a good form of ego-strengthening) and with encouragement and
reassurance that all is going well. This also means that the next stage or the
next treatment session will be easier.
Unfortunately, some patients' dental anxiety may be so severe that they
never go to see a dentist, and therefore dentists may not see many dental
phobics at all. Such patients may 'break into a cold sweat' when anything
about dentistry is mentioned in their presence, and may even be afraid of
cleaning their teeth, or they do so under great sufferance. Hence, this causes
their teeth to deteriorate to an appalling condition and this often contributes
to poor self-esteem, distancing from relationships, a failure to achieve certain
goals in life, and a host of physical and emotional problems, including social
phobia and agoraphobia. Therefore, clinical psychologists, psychiatrists and
general medical practitioners are often the first point of contact with these
patients (whom they may be seeing for other reasons). Even though dental
practitioners trained in the treatment of the dentally phobic patient are often
the best people to treat them, they may have to provide a special room that
bears no resemblance to the dental surgery and has a separate entrance. This
may be obligatory if the dentist is to persuade such patients to seek treatment
in the first place. The therapy can, however, start with a non-dental therapist
and be carried on by a dentist trained in hypnosis, once the patient reaches
the point of being able to see a dentist (though not to go through any dental
procedure). In the final stage of the therapy, the patient obviously has to be
exposed to the actual dental surgery and treatment.
Case examples
Patients resistant to the above programme may, as we have seen earlier, benefit from a
psychodynamic approach. A patient, Jenny, in her late 30s approached the therapist
(KKA), who was also her GP. with a problem of panic attacks. She normally worked at
a supermarket check-out but she had become unable to go to work because of panic
attacks that started to happen when there were people around. Her marital relationship
began to suffer as she was becoming more and more housebound, could not go on
holiday, and could not accompany her husband motorcycle racing, something that she
normally loved to do. She also felt that she was being ridiculed by her children.
(continued)
29: HYPNOSIS IN DENTISTRY 407
Case examples {continued)
After several sessions of ego-strengthening and counselling, she had the courage to
tell the therapist that it was dental phobia that was the root cause of her problems. She
did not dare to open her mouth in front of anybody because her teeth were in such bad
condition. She had not seen a dentist since she was 10 or 11 (after which age she could
refuse her parents' instructions to do so), but could not understand the reason.
During hypnosis, she was asked, as her 'adult self, to imagine travelling back
through her life looking for the earliest memory of her being troubled and frightened.
(This is a variation of the affect bridge method, the patient being an 'observer' or 'dissociated'.)
She then reported seeing herself at the age of 6 suffering from toothache and
being on the way to the dentist. Her father was quite cruelly telling her that if she did not
behave, the dentist would cut her head off; he would then have to sew it back on again,
and there would be a large scar on her neck. The little girl firmly believed that she would
come back without her head. The adult self was then instructed to help and reassure the
7-year-old child (see Ch. 19).
The care of this patient was then transferred to a dentist trained in hypnosis, who
carried out the desensitisation programme with no problems and all her teeth were
restored. Jenny then experienced a new lease of life.
Naomi, who was 17 years old, ran 3 miles non-stop to her home, raced upstairs, and sat
on her bed, panting with fear. Her grandmother, who had just been with her in the local
hospital dental department, then arrived back by bus. All that had happened was that
the junior dental surgeon approached Naomi with a needle and syringe to take some
blood prior to a dental operation. She had been referred to the hospital because she
refused to see her family dentist as she had a phobia of needles and dentists.
She failed to respond to a desensitisation programme, A psychodynamic approach
was then pursued using Wolberg's theatre visualisation technique (Ch. 19). She began
describing a set of bright lights and a man appearing in a white coat. With undue eagerness,
the therapist (KKA) intervened by asking. 'Is that man a doctor?' She then alerted
herself, very distressed. The session continued with the reinstatement of hypnosis and
relaxation. Naomi was then asked to watch her 'dissociated ego' at an easel painting
pictures concerning her problem. She then spontaneously regressed to the age of 7.
She was alone in the dentist's chair, frozen with fear, and unable to talk or cry. as her
mouth was held wide open. The dentist was 'poking around with a needle' prior to
extracting one of the teeth. Naomi began to whimper and when allowed to cry, she 'let
it all out'. All she (the child) wanted at that time was to have her mummy hold her hand
and then the dentist could do whatever was needed.
Naomi's grandmother, who was chaperoning her during the hypnosis session, was
recruited in the role of her mother and held her hand and comforted '7-year-old Naomi'.
Little more was needed. On alerting, Naomi showed no signs of anxiety as she took a
needle and syringe in her hand and then allowed the therapist to take a blood sample.
Most often, dental phobia is linked to a bad experience in the dental surgery
(Ost 1985). We also sometimes hear horror stories as young children.
These expectations may then be confirmed at the dentist's by what otherwise
might have been only minor pain, but which is now perceived as 'terrible
hurt'. Treatment may be focused on unravelling such memories, which
are understandable but based on distorted information, and encouraging
the 'younger self to have a more realistic perception and understanding
with the help of the 'adult self in conjunction with a trusted therapist.
Hypnosis can be the best medium to achieve this.
408 MEDICAL AND DENTAL HYPNOSIS
REFERENCES
Bartlett K A 1971 Gagging. A case report. American Journal of Clinical Hypnosis 14: 54-56
British Dental Association 1995 Dental phobia. Fact file, June. British Dental Association,
64 Wimpole Street, London WIM SAL
Dubin L L, Shapiro S S 1974 Use of hypnosis to facilitate dental extraction hemostasis in a
classic hemophiliac with a high antibody titer to Factor VIII. American Journal of Clinical
Hypnosis 17: 79-83
Enqvist B, von Konow L, Bystedt H 1995 Pre- and perioperative suggestion in maxillofacial
surgery: Effects on blood loss and recovery. International Journal of Clinical and
Experimental Hypnosis 43: 284-294
Hopkins B, Jordan J M, Lundy R M 1991 The effects of hypnosis and of imagery on bleeding
time: A brief communication. International Journal of Clinical and Experimental Hypnosis
139: 34-139
Humphries G, Morrison T, Lindsay S 1995 The modified Dental Anxiety Scale; Validation
and United Kingdom norms. Community Dentistry and Oral Epidemiology 12: 143-150
LeBaron S, Zeltzer L K 1984 Research on hypnosis in hemophilia - preliminary success and
problems: A brief communication. International Journal of Clinical and Experimental
Hypnosis 32: 290=295
Lichstein K L, Eakin T L 1985 Progressive versus self-control relaxation to reduce
spontaneous bleeding in hemophiliacs. Journal of Behavioral Medicine 8: 149-162
Lucas O N 1975 Use of hypnosis in hemophilia dental care. Annals of the New York
Academy of Sciences 240:263-266
Ost L G 1985 Mode of acquisition of phobias. Acta Universitatis Uppsaliensis (Abstracts of
Uppsala Dissertations from the Faculty of Medicine) 529: 1-45
Pierce C J, Christman K, Bennett M E et al 1995 Stress, anticipatory stress, and psychological
measures related to sleep bruxism. Journal of Orofacial Tain 9: 5-16
Swirsky-Sacchetti T, Margolis C G 1986 The effects of a comprehensive self-hypnosis training
program on the use of factor VIII in severe hemophilia. International Journal of Clinical
and Experimental Hypnosis 34: 71-83
FURTHER READING
We thoroughly recommend the following monograph that is devoted to hypnosis in dental
practice and contains chapters on history; the hypnotic treatment of dental anxiety and
phobia in adults and children, gagging and denture intolerance, bruxism, TMJ dysfunction;
and pain management.
Mehrstedt M, Wikstrom P-O (eds) 1997 Hypnosis in dentistry. Hypnosis International
Monographs, number 3. MEF-Stiftung, Konradstrasse 16, 80801 Munich, Germany
Below is a selection of individual papers on topics that we have covered in this chapter.
Barsby M J 1994 The use of hypnosis in the management of 'gagging'. British Dental Journal
176:97-102
Clarke J H, Persichetti S J 1988 Hypnosis and concurrent denture construction for a patient
with a hypersensitive gag reflex. American Journal of Clinical Hypnosis 30: 285-288
Clarke J H, Reynolds P | 1991 Suggestive hypnotherapy for nocturnal bruxism: A pilot study.
American Journal of Clinical Hypnosis 33: 248-253
Eli I, Kleinhauz M 1985 Hypnosis: A tool for the integrative approach to the treatment of the
gagging reflex. International Journal of Clinical and Experimental Hypnosis 33: 99-108
Forgione A G 1988 Hypnosis in the treatment of dental fear and phobia. Dental Clinics of
North America 32:745-761
Golan H P 1989 Temporomandibular joint disease treated with hypnosis. American Journal
of Clinical Hypnosis 31: 269-274
29: HYPNOSIS IN DENTISTRY 409
Kelly M, McKinty H, Carr R 1988 Utilisation of hypnosis to promote compliance with routine
dental flossing. American Journal of Clinical Hypnosis 31: 57-60
Rodolfa E R. Kraft W. Reilley R R 1990 Etiology and treatment of dental anxiety and phobia.
American Journal of Clinical Hypnosis 33: 22-28
Thompson S A 1994 The use of hypnosis as an adjunct to nitrous oxide sedation in the
treatment of dental anxiety. Contemporary Hypnosis 11: 77-83
SECTION 5
The professional practice of
hypnosis
In the final two chapters of this book we broach a
number of themes that should receive the attention
of the serious researcher, practitioner and teacher of
hypnosis. In Chapter 33 we raise the question of
whether there is any evidence that the procedures we
have described in this book actually work. Our review
of the existing evidence should lead the reader to
conclude that there are good indications that hypnotic
procedures are of significant benefit for a remarkable
range of problems commonly encountered in medical,
dental and psychotherapeutic practice.
We also take the opportunity in Chapter 33 to explore
the evidence for the benefits of using hypnosis in
forensic investigation and arrive at a more guarded and
sceptical conclusion. Finally in this chapter we again
return to the theme of possible adverse effects of
hypnosis and do so with a consideration of
inadequately trained or lay therapists, and stage
hypnosis. We note that, while there are reasons to
consider that adverse consequences may arise from
both, there is as yet a dearth of systematic evidence
and we urge the reader to take an objective and
balanced perspective.
In the final chapter we impress upon the reader the
importance of understanding hypnosis and its
application from the standpoint of mainstream
psychology, medicine and related disciplines. To this
end we offer advice concerning the current academic
literature on hypnosis and the existence of learned
societies for professional practitioners.
Appendices
APPENDICES CONTENTS
1. Clinical hypnosis and memory 501
2. Ethical guidelines of the International Society of
Hypnosis 505
Appendix 1
Clinical hypnosis and memory
Appendix contents
On memory 501
On hypnosis and memory 502
Guidelines for clinical practice: standards of care with possibly
traumatised clients 502
The following statements and guidelines for members of the British Society
of Experimental and Clinical Hypnosis (BSECH) are based primarily on
Brown (1995), Williams (1995), the American Society of Clinical Hypnosis
Guidelines on Clinical Hypnosis and Memory (Hammond et al 1995), the
British Psychological Society Report on Recovered Memories (1995) and the
collection of papers published in Conway (1997).
ON MEMORY
There is a generally accepted view in cognitive psychology that there is
more than one memory system in humans, that memory is reconstructive
rather than reproductive and is generally better for central events rather
than peripheral details. Whatever the methods used in the process of
retrieving material from memory, some of the information retrieved will be
accurate and some will be inaccurate. The only certain way of distinguishing
between the two is independent corroboration of the original events.
Suggestion, expectancy and post-event misinformation can lead to the
creation of false memories (pseudomemories), especially in individuals
who are high in hypnotisability or interrogative suggestibility, where there
is uncertainty about detail, and in conditions of anxiety and stress. Most of
the relevant work on memory and pseudomemory has involved laboratory
or experimental situations which may not reflect accurately the processes
involved in memory for traumatic events. There is growing evidence
that 'traumatic memory' is processed differently from narrative memory
(memory for non-traumatic everyday events). There is also evidence that
traumatic events may be experienced as partially or wholly forgotten by the
individual and then recalled very much later. Though further research is
needed, there are reports which suggest that in some cases these so-called
'recovered memories' reflect events which actually happened and for
which corroborative evidence exists, whilst in other instances there may be
501
502 MEDICAL AND DENTAL HYPNOSIS
no such corroborative evidence. Whenever a clinician asks about a client's
history, the situation is created for possible false memory production and
the beliefs of therapists may set the scene for pseudomemories. This is a
most significant consideration perhaps when, as in victims of trauma or
abuse, the events subject to recall may be considered central to the client's
presenting problem.
ON HYPNOSIS AND MEMORY
Hypnosis by itself should not be assumed to make memory retrieval either
more accurate or less accurate. Hypnosis is an adjunctive procedure which,
through processes such as enhanced absorption and imaginal involvement,
might be expected to facilitate established procedures, such as repeated
retrieval and contextual reinstatement, which are held to improve recall.
Hypnotic procedures may also facilitate access to painful or traumatic
memories and assist in their integration by providing a safe context for
recall. On the other hand, if an individual is highly hypnotisable, whether
or not formal hypnotic procedures are used, suggestion and post-event
misinformation may lead to inaccurate or distorted memories. The hypnotist's
and the subject's expectations and beliefs about the effects of hypnosis
on memory may also influence the process of recall. In particular, a hypnotic
context may increase confidence in the validity of material which is
recalled whether or not it is objectively accurate, though research has
shown that this effect is reduced or even eliminated if prior warning is
given that it might occur. Hypnotic procedures are relevant to the question
of memory recovery following a period of apparent memory loss. For
example, hypnosis can be employed in experimental settings to create temporary
amnesia which can later be followed by accurate recall of some or all
of the 'forgotten' material. The latter does not prove, however, that material
recovered in this way in other contexts is necessarily accurate or that
similar memory recovery effects would be seen in the case of trauma.
Considerable experimental research has shown that hypnotic age regression
is not a literal return to an earlier physiological or psychological stage
of development and the apparently recalled material which forms the basis
for the regression experience may be both accurate and inaccurate in an
historical sense.
GUIDELINES FOR CLINICAL PRACTICE: STANDARDS
OF CARE WITH POSSIBLY TRAUMATISED CLIENTS
The following guidelines are intended to apply to all clinicians whose work
brings them into contact with survivors of trauma and abuse. Because hypnosis
may be expected to facilitate both good and bad practices in therapy,
and in light of views which have been widely expressed about the role of
CLINICAL HYPNOSIS AND MEMORY 503
hypnosis in creating false memories, those therapists who employ hypnosis
in their work should be especially mindful of good clinical practice.
Concerning the nature of therapy
Classic abreaction and the use of memory recovery techniques as a main
focus of treatment are contraindicated.
What is preferred is a phase-oriented treatment approach with three main
stages:
1. Stabilisation: management of intrusive re-experiencing symptoms,
developing coping strategies and skills.
2. Systematic uncovering: a graduated process of integrating memories
and associated affect related to the trauma into current biographical
memory and awareness, using primarily free recall and memory
integration methods.
3. Postintegratve support: developing new social competencies and
self-esteem.
Concerning the dangers of false memory production
in therapy
The likelihood of creating false memories is reduced if:
a. the client gives informed consent following discussion of what is
known from current research about the nature of human memory and
an explicit statement that not all memories recovered in treatment are
accurate.
b. the therapist recognises a duty to both the client and the community.
Clients should not be encouraged to cut off from family or friends or
sue as part of therapy, even when abuse memories are corroborated, as
this is rarely beneficial therapeutically and is arguably not part of the
therapist's role.
c. the risks are assessed, especially with clients with post-traumatic stress
symptoms but no identifiable stressor or memories of abuse. Risks
which are commonly identified include:
high hypnotisability
high interrogative suggestibility (where interpersonal pressure is
added to post-event suggestion (Gudjonsson 1984))
deep involvement with self-help trauma groups or their literature.
d. the therapist assesses personal beliefs and biases about possible trauma
and its treatment, especially when assessing new patients. The belief
that trauma is the primary cause of most psychological problems
and that memory uncovering is the primary treatment is likely to
create conditions conducive to the development of false memories
504 MEDICAL AND DENTAL HYPNOSIS
by the client. Uncritical acceptance that trauma did not occur is as
unjustifiable as lightly accepting statements of trauma as fact. After a
thorough assessment, the therapist should treat the condition
presenting and not the condition suspected.
e. the therapist is informed about current memory research and its
relevance to clinical settings.
f. the therapist is aware of the role of suggestion in memory distortion
and does not use persuasive techniques or interrogative methods,
but adopts a more egalitarian and permissive approach.
g. free-recall strategies are adopted (not structured enquiry or leading
questions).
h. anxiety, distress and uncertainty about the course of therapy are kept
to a minimum,
i. the client is assisted in tolerating ambiguity and uncertainty about the
past and not pushed towards 'disambiguation' or to 'remember more'.
REFERENCES
British Psychological Society (BPS) 1995 Recovered memories: The report of the working
party of the British Psychological Society. BPS Publications, Leicester
Brown D 1995 Pseudomemories: The standard of science and the standard of care in trauma
treatment. American Journal of Clinical Hypnosis 37: 1-24
Conway M A (ed) 1997 Recovered memories and false memories. Oxford University Press,
Oxford
Gudjonsson G H 1984 A new scale of interrogative suggestibility. Personality and Individual
Differences 5: 303-314
Hammond D C, Garver R B, Mutter C 13 et al 1995 Clinical hypnosis and memory: Guidelines
for clinicians and for forensic hypnosis. American Society of Clinical Hypnosis, Des Plaines
Williams I. M 1995 Recovered memories of abuse by women with documented child sexual
victimization histories. Journal of Traumatic Stress 8: 649-674
Acknowledgement
This document has been prepared by Dr David Oakley and Mrs Marcia
Degun-Mather of the British Society of Experimental Hypnosis (BSECH)
with the advice of members and Council officials of the BSECH. It is
reprinted here with the permission of the BSECH.
Appendix 2
Ethical guidelines of the International
Society of Hypnosis (Ratified August
1979 - currently under revision)
Appendix contents
Guideline 1 505
Guideline 2 506
Guideline 3 506
Guideline 4 506
Guideline 5 506
Guideline 6 507
The International Society of Hypnosis (ISH) is dedicated to the scientific
investigation and clinical utilisation of hypnosis at the highest professional
level. Ethical guidelines to which a member must subscribe are stated to
allow for the multidisciplinary nature of the membership. There is implied a
personal commitment to behave according to high standards of personal
and professional conduct.
GUIDELINE 1
1. A member of ISH shall always place first the welfare of the patient or
the experimental subject when using hypnosis or hypnotic techniques in
clinical practice or in experimentation.
a. The standards of professional relationships which guide the
physician, dentist, psychologist (with doctoral degree), or other
defined professional worker, within the appropriate professional
or scientific field, shall prevail in his or her use of all hypnotic
techniques.
b. Proper safeguards shall be maintained whenever a patient or
subject is exposed to unusual stress or other form of risk. If stress
or risk is involved, the person or subject should be informed and
give consent. Estimation of risk is a difficult matter, and when in
doubt the practitioner should consult with professional
colleagues.
505
506 MEDICAL AND DENTAL HYPNOSIS
GUIDELINE 2
2. Hypnosis is considered an adjuvant to other forms of scientific or clinical
endeavours, so that competence in hypnotic techniques alone is not
acceptable as a basis for professional service or research.
a. In view of the dependence of hypnotic practice upon other
qualifications, the membership requirements of ISH require proper
standing in the recognised national organisations, whether clinical
or scientific, appropriate to the field of competence not represented
by hypnosis. That is, a medical doctor is expected to belong to the
appropriate medical association, a dentist to the appropriate dental
association, a psychologist to the appropriate psychological
associations, and so on.
b. Item 2a requires acceptance of the ethical and scientific standards of a
responsible professional organisation. It does not imply endorsement
by ISH of the particular policies or practices of any particular
organisation.
GUIDELINE 3
3. Each member of ISH shall limit the clinical and scientific use of hypnosis
to the area of competence as defined by the professional standards of his
or her field.
GUIDELINE 4
4. Hypnosis should not be used as a form of entertainment.
a. No member of ISH shall offer services for the purposes of public
entertainment or collaborate with any person or agency engaged in
public entertainment.
GUIDELINE 5
5. A member of ISH shall not support the practice of hypnosis by lay
persons.
a. A lay person is defined here as one who is not a member in good
standing of a therapeutic or scientific profession; that is, he or she is
not a physician, dentist, psychologist, or member of another recognised
therapeutic or scientific profession with credentials in addition to
competence as a hypnotic practitioner.
b. A member of ISH shall not give courses involving the teaching of
hypnotic techniques to lay individuals who lack training in a relevant
science or profession. Lectures informing lay individuals about
ETHICAL GUIDELINES OF THE INTERNATIONAL SOCIETY OF HYPNOSIS 507
hypnosis are of course admissible providing they do not include
demonstrations or didactic material involving inducting of hypnosis.
c. Exceptions are made to students, in training in the appropriate sciences
or professions. While ISH explicitly recognises that hypnosis is not an
independent science or art, the technique may appropriately be utilised
by nurses or paramedical assistants under the immediate and direct
supervision of an individual whose credentials and training would
permit membership in ISH and who has an agreed commitment to this
Code of Ethics either directly or through a National Constituent Society.
Special arrangements can be made for the training of such nurses or
paramedical personnel provided that arrangements have been made for
such individuals to work directly under the supervision of an ISH
member or the equivalently trained professional as outlined.
d. Consultations with lay representatives of the press or other media
of communication are permitted to minimise distortions or
misrepresentations of hypnosis. Talks with lay representatives of
the press and radio or TV appearances are welcomed so long as these
benefit the Society from wise and informed views on issues in
hypnosis.
GUIDELINE 6
6. It is recognised that an ethical code cannot by its very nature specify all
of the practices that are considered ethical and mention all of those
considered unethical. Hence, behaviour in accordance with the ethical
norms of the nations in which the professional worker or scientist lives
are taken for granted, and violation of these norms (e.g. through illegal
behaviour, or discordant behaviour that brings disrepute upon others
who practise hypnosis) may be the occasion for adverse action by the
ISH, even though not specified in this code.
Acknowledgement
From the International Society of Hypnosis Membership Directory 1997
International Society of Hypnosis, West Heidelberg, Australia, p 75-76.
Reprinted with the permission of the International Society of Hypnosis.
Index
Abreaction, 5-6,185,238,248, 289, 503
severe, avoidance of, 291
Absorption, 25, 25-26,34,48, 96
children, 156
induction and deepening, 67-81
Abstention, smoking cessation
cutting down vs complete abstention, 298
immediate vs gradual, 297
rates, 296-297, 476
Abuse, 272, 444
'recovered memories' of, 209, 210
Accident and emergency, pain
management, 360
Active distraction techniques, children,
467
Active-alert methods, 117, 118
depression, 439
weight reduction, 312
Adverse effects, 287-288, 485-487
stage hypnosis, alleged, 480-481
Aesculapius, 5
Affect bridge method
age regression, 233
anxiety disorders, 420
dentistry, case example, 404
psychosomatic problems, 327
Affirmations
smoking cessation, 259, 302
weight reduction, 311,447
Age progression, 22, 235-236, 286
cancer patients, 374,376
childhood eczema, 464
dental phobia, 405
psychosomatic problems, 336
smoking cessation, 301-302
weight reduction, 311, 313
Age regression, 22, 229-235, 285-286, 502
and abreaction, 289
applications, 234-235
contraindications, 231
counselling the 'child', 239-240
and ego-state therapy, anxiety, 420
ideomotor signalling, 221, 232-233
methods, 232-234
psychosomatic problems, 336
session, conducting, 230-232
stuttering, 450
Age and susceptibility, 33
Alert methods, induction, 117-118
Alerting the patient, 76-77
age regression, 231
Alladin's cognitive hypnotherapy for
depression, 437139
Altered states of consciousness, 24, 25
Alternatives, indirect suggestion, 112
American Journal of Clinical Hypnosis, 474,
495
Amnesia, 22, 26
amnesic barriers, 45
Analgesics, 351
Anchoring
combining positive and negative,
139
positive feelings, 138, 376, 402, 405
posthypnotic suggestion, 141-142
relaxation, bruxism, 401
Anecdotes
literal, 143-144
metaphorical, 144-150
Anger and hostility
clenched fist procedure, 139
PTSD, 431
Animal magnetism, Mesmer, 6-7
Anorexia nervosa, 445, 446, 447
Anticipated pain, dentistry, 399
Anticipatory anxiety, 419
Anxiety, 290, 411-432
behaviour therapy, 262-263
children, 467-179
cognitive model for, 278-280
infertility, 380, 381
manifestations of, 411-414
and morning sickness, 384
and pain, 350, 351
stuttering, 450
treatment approaches, 414420
see also Obsessivecompulsive disorder;
Phobias; Post-traumatic stress
disorder (PTSD)
Arm
catalepsy, 20,94-95
heaviness from resting position, 73
levitation, 93-94
children, induction and deepening,
160-161
with eye fixation, 95
ideomotor suggestions, 19
pain management, 356
509
510 INDEX
Arm (continued)
lowering
age regression, 233
ideomotor suggestions, 19-20, 87-88
rigidity, ideomotor suggestion, 20
Arms coming together suggestion, 89
Arousal
human performance, 452
reduction in, physiological anxiety, 416
Asklepios see Aesculapius
Assessment
hypnosis in eclectic psychotherapy, 285
importance of thorough, 288
insomnia, 317-318
pain management, monitoring and
progress, 351-353
psychosomatic problems, 324-326,330
smoking cessation, 298-299
weight reduction, 309-310
Assessment scales, mood and anxiety,
324-325
Asthma, 337-338
children, 461
Attention, 48
Attention-switching strategy, physiological
anxiety, 416
Attentional biases, correcting physiological
anxiety, 416
situational phobic anxiety, 417-418
Attitude to pain, 350
Attribution, 52-55
Audiotaping session see Tape recording
of session
Auditory hallucinations, 20-21
Authoritarian vs permissive suggestions,
107-108
Autogenic discharges, 79
Automatic writing and drawing, 249-250
Aversion
learning, 257
therapy, 264-266
Avoidance, 272, 425
and exposure, reality testing, 277
PTSD, 431
trait anxiety, 413
see also Escape and avoidance
Banyai, Eva, 118
Beach ball and bucket, induction and
deepening, 161-162
Beck, Aaron T, 278
Behaviour therapy, 255-268
avoidance, approach to, 273
basic procedures and hypnotic
augmentation, 258268
body image, changing, 448
hypnotic procedures, incorporation of, 268
origins and nature, 255-258
self-control, 135-142
weight reduction, 307-308
Behavioural
anxiety, 418
explanation, PTSD, 424
Behaviourism, 13, 255-256, 257-258
Benefits of hypnosis, 485
Bereavement, metaphors for, 150-153
Berne, Eric, 189
Bernheim, Hippolyte, 11-12
Biofeedback, 176-178
Bleeding, control of dentistry, 400-401
general surgical procedures, 359,360
Blepharospasm, 340
Blink rate, 91
Blowing bubbles technique, 136-137
posthypnotic suggestion, 141
Blushing, 266-267,267
Body image, changing, 448
Body-mind communication, 332-333
Bonding, pregnancy, 383-384
Borderline personality disorder, 290
Braid, James, 10-11
Breathing methods, induction, 71-73
Breathing techniques, self-control,
136-137
posthypnotic suggestion, 141
Britain
criminal justice system, 479
stage hypnosis, 481-483
British Medical Association, 14
The British Society of Experimental and
Clinical Hypnosis (BSECH), 494, 495
statements and guidelines
hypnosis and memory, 211, 502
on memory, 501-502
standards of care, possibly traumatised
clients, 502-504
The British Society of Medical and Dental
Hypnosis (BSMDH), 494,495
The British Society of Medical and Dental
Hypnosis (Scotland), 494
The British Society for the Practice of
Hypnosis in Speech Therapy, 449
Bruxism, 398, 401
The bubble technique, traumatic memories,
428
Bulimia nervosa, 445, 445-446
cognitive-behavioural therapy, 446
ego-state therapy, 448-449
Cancer, 365-376
applications of hypnosis, 372
communication in management and
treatment, 369-371
hypnotic procedures, 372-376
INDEX 511
pain management, 359, 375-376
personality, stress and, 365-366
psychological approaches in
treatment, 371-376
psychoneuroimmunology, 366-369
side effects, neutralizing, 374
Cancer prone personality, 366
Carleton Skill Training Program, 52
Chaperone, 98-99
working with children, 458
Charcot, Jean Martin, 11-12
Chevreul's pendulum, 19, 90
ideomotor signalling, 218
Child sexual abuse, 209, 210, 272, 444
Children and adolescents, 155-169,250-252,
457-469
distraction, dentistry, 400
ego-strengthening, 163-164
experience and behaviour during
hypnosis, 155-156
exploration at problem, 460
general considerations, 155-156, 457-460
induction and deepening methods,
157-162
posthypnotic suggestion, 163
preparation and preliminaries, 156-157
psychodynamic therapy, 250-252
self-control, 164-165
self-hypnosis, 162-163
specific conditions, procedures for,
460-167
Storytelling, use with children, 165-169
Choice or permission, creating illusion of,
110-111
Chronic pain Syndrome, 361-362
Orcadian and ultradian rhythms, 316
Clenched fist technique
anchoring, self-control, 137-139
anger control, 139
pain, 357
Clinical anxiety, 414
Cognitive anxiety, 419420
model for, 278-280
see also Worrying
Cognitive factors, pain, 349-351
Cognitive flexibility, susceptibility, 35-36
Cognitive rehearsal
bruxism, 401
future and past situations, 286
problem situations, 285
Cognitive restructuring, 276,418, 426, 429
situational phobic anxiety, 418
Cognitive schema see Schemas
Cognitive therapy, 173-174, 271-280
anxiety, treatment aims, 415
comparison with other psychotherapies,
277-278
fundamentals of, 275-280
hypnosis, application of, 280
problems and therapies, 271-275
situational anxiety, 417418
situational phobic anxiety, 418
variations, 278
Cognitive unconscious, 206
Cognitive-behavioural therapy
anxiety, 420
bulimia nervosa, 446
depression, 436-437,437-439
planning future activities, 440141
effectiveness of hypnosis in, 475
obsessive-compulsive disorder,
420-421
Coin or linger nail, children, induction and
deepening, 159-160
Coloured vapour technique, 136, 357
Communication
by allegory and symbol, 146
facilitated, 225
management and treatment, cancer
patient, 369-371
two-stage model, 223
Compensation claims, 361, 422123
Complementary medicine, 5
Complex suggestions, 22
Compliance, 23, 37, 48-51, 56
ideomotor signalling, 220
Complications, 78-80
Compulsive habits, massed practice, 268
Confabulation, 230,477
Confusion technique, 114
Consciousness, 205-206
and role of psychotherapy and hypnosis,
208-209
Contemporary Hypnosis, BSECH, 495
Conversational approach, indirect
suggestion, 114-115
The Cook Report, Central Television, 493
Coping
anxiety-provoking thought,
avoidance of, 213
ego-state therapy, 241
resolving memories, 241
Core belief system and traumatic
experiences, 425
Counter-conditioning, 262-263
Covert aversion therapy, 264266
Covert modelling
behaviour therapy, 261-262
children, induction and deepening, 159
Covert rehearsal
self-control methods, 139-141
smoking cessation, 303
Covert reinforcement
self-control, augmenting, 260
smoking cessation, 302
weight reduction, 311-312
512 INDEX
Creative fantasising, cancer patients, 373
Creative Imagination Scale, 31, 32, 87, 326
children, 155
Criminal justice system, forensic hypnosis,
478-479
Crisis, 5
see also Abreaction
Cromwell, portrait, metaphors and
stories, 149-150
Crystal ball fantasy, 251
Cue word, depressive thinking
patterns, 439
Cytokines, 367
De-regressing, age regression, 231
Death following stage hypnosis, 482
Decline of hypnosis, 12-13
Definition, hypnosis, 55
Delusional states, 290
Dental phobia, 397, 399, 404-407
Dentistry, 397-407
bleeding, control of, 400-401
bruxism, 398,401
chaperones, 99
dental phobia, 397, 399, 404-407
gagging, 398, 401-403
general considerations in treatment,
398-399
legal and ethical issues, 398
pain and discomfort, amelioration of,
399-400
temporomandibular joint
dysfunction, 398, 403-404
Depression, 290, 436-441
cancer patients, 371-372
psychotherapy, 436-437
augmented by hypnosis, 437-441
PTSD, 423,431-432
Depth of trance, 26
Dermatological complaints, 338-399
children, 464-466
Describing hypnosis, 64-65
Desensitization, 262-263
dental phobia, 405-406
gagging, 402
panic attacks, 273
phobias, children, 468
Developmental model, anxiety,
278-280
Diagnostic scan, age regression, 232-233
Diagrams, working with children, 462
Diaries
pain, 353
weight reduction, 307, 309
Dichotomies, indirect suggestion, 112
Direct symptom control, physiologial
anxiety, 415
Direct vs indirect suggestions, 108-117
Displacement, pain, 358
Dissociated control, theory of, 43-44
Dissociation, 12
age regression, 229
pain, 358
PTSD, 424
and susceptibility, 35
'Dissociation method', rehearsal and
practice, 259
Dissociative Experiences Scale, 35
Dissociative identity disorder, 191, 210-211,
222, 290
Distraction
children, 467
dentistry, 400
pain management, 354
Distress, signs of, 79-80, 288
Dowsing, 225
Dreams
analysis, 184, 188, 243-247
hypnotic dreams and fantasies, 247-249
suggestion, 246-247, 404
Drifting off, patient, 78
Duodenal ulceration, 342-343
Dysfunctional thoughts and beliefs, 275
Dystonia and tics, 340-341
Eating disorders, 308, 445-449
response prevention, 264
Eclectic psychotherapy, 283-286
aims and rationale, 283-284
hypnosis, application of, 284-286
Eczema, 339, 464-465
Edmonston, William, 41
Education
cognitive therapy, 275
infertility, 380
labour and delivery, 386-387
psychosomatic problems, 330, 331
Effectiveness of hypnosis in therapy,
evidence for, 473176
Ego-shrinking, 266-267
Ego-state therapy, 240-241
and age regression, anxiety, 420
eating disorders, 448-449
ideomotor signalling, 221-222
PTSD, 427
stuttering, 450
weight reduction, 313
Ego-states, 189-190
importance for clinical hypnosis, 190-191
Ego-strengthening, 126-133
applications, 126-127
cancer patients, 375
children, 163-164
depression, 438
INDEX 513
direct and indirect suggestion, 109
eating disorders, 447
guidelines, summary, 132-133
Hartland's routine, 127-129
Heap's routine, 129-130
psychosexual problems, 443
psychosomatic problems, 335
school phobia, 468
self-control, 142
symbolic and metaphorical imagery,
130-132
weight reduction, 312
Elliotson, John, 9-10, 397
Ellis, Albert, 278
Embedded suggestions, 110
Empty chair technique, Gestalt
psychotherapy, 188
Erickson, Milton, 108, 193-198
Ericksonian approaches,
psychotherapy, 193-198
impact on modern practice, 197-198
refraining, 196-197
resolution phase, 195-196
trance, 109-110, 197
unconscious resources, 194-195, 202
utilisation, 195
Escape and avoidance
cognitive approach., 273-274
PTSD, 431
Esdaile, James, 10
Ethical guidelines, 446-448
International Society of Hypnosis, 1979,
505-507
Ethics, 97-99
hypnosis in dentistry, 398
working model, concept of, 180-181
Evidence, benefits and adverse effects
adverse effects, 485-487
benefits, 485
effectiveness in therapy. 473476
forensic investigation, 476-479
hypnotherapy, 473-487
intrinsic risks, 474
risks, inadequately trained therapists,
483-485
stage hypnosis, 480-483
Executive ego, 44-45
Exercise, weight reduction, 305-306
Exhibitionism, aversion therapy, 264-266
Expectation, 48
and confidence, building patient, 87-90
recovered memories, fact and fantasy,
212,477
susceptibility, 34
Experts, identifying the, 493494
unqualified 'expert' witness, 479, 493
Exposure therapy, phobias, 415
Extinction, behaviour therapy, 261
Eye
' catalepsy, 20,93
closure, children, 155
fixation, 91-92
and arm levitation, 95
and arm lowering, 92
Eye-movement desensitization and
reprocessing (EMDR), 428-424
Eye-roll method, 70-71
Eves open-eyes closed method, 92-93
Eyewitness recall, 476-478
Facilitated communication, 225
False accusations against practitioner,
98, 99
False memories, 211, 289, 477, 478, 486,
501
minimizing danger of producing,
503-504
sexual abuse, 483
Fantasy
creative, cancer patients, 373
procedures, psychodynamic therapy,
242-250
psychosexual problems, 443
susceptibility, 34,48
Faria, Abbe de, 9
Federation of Ethical Stage Hypnotists, 481
Feedback, behaviour therapy, 259
biofeedback, 176-178
Fees arid motivation, 294
Finger
lock, 20, 89-90
movements, ideomotor signalling,
218-220
'First aid for depression', 438
First and later sessions, 80-81
Flooding, behaviour therapy, 263
Flying, fear of, 272, 419, 468
Food
controlling availability, 307-308
diary, weight reduction, 304
see also Eating disorders
Forensic investigation, hypnosis in,
476-479, 486
Formative experiences, 279-280
Fractionation technique, 76
Franklin Inquiry, 1784, 7-8
Free association, 184
Free metaphorical imagery, 336-337
Freud, Sigmund, 13, 183
dream interpretation, 243
incest, 210
theoretical concepts, 184
Fruit, imagery, 15-16, 88
Future rehearsal in imagination, 140-141
Future, visualising the see Age progression
514 INDEX
Gagging, dental procedures, 398, 401-403
Galen, 4
Games People Play, Berne, 189
Gastro-intestinal problems,
psychosomatic, 341-343
Gate Control Theory, pain, 357
Gates vs McKenna, 482
Gender, susceptibility, 33-34
General and specific effects of
treatment, 178-179, 323-324
General surgery, pain management,
359-360'
Generalised anxiety disorder, 414, 415
Gestalt therapy, 187-189
Glove anaesthesia, 16,22-23, 89
dentistry, 400
eczema, 339
gagging, 402
pain management, 355-356
Graded exposure, behaviour therapy,
262-263
Grief
and infertility, case example, 382, 383
metaphors
bereavement, 150-153
cancer patients, 371
Group treatment, 81, 289
psychosomatic problems, 328
smoking cessation, 297-298
ulcerative colitis, 343
weight reduction, 313
Guided
fantasy, children, 158
imagerybreast
cancer, 368-369
infertility, 381
Gustatory hallucinations, 21
Gut-directed therapy, 342
Gynaecological conditions, 392-394
Habit reversal, 266, 451
Habits, common nervous, 451
Habituation, 263
Haemostasis
dentistry, 400-401
general surgical procedures, 359, 360
Hand-on-abdomen technique
duodenal ulceration, 342-343
irritable bowel syndrome, 342
pain, 357
self-control, 137
Hands in healing, 4
Hartland
ego-strengthening routine, 127-129
unconscious mind, 201
Harvard Group Scale of Hypnotic
Susceptibility, 30
Hayward, Lionel, 476
Headache, 176-178,343
Healing, common themes and
practices, 3-6
Healthy eating, weight reduction, 305
Heap's ego-strengthening routine, 129-130
Hell, Father Maximillian, 6
Hidden observer
in age regression, 230-231
pain, 45-46
Hippocrates, 365
History of hypnosis, 3-14
History taking
children, 459-460
nocturnal enuresis, 462
Home Office Model Conditions on the
Conduct of Stage Hypnosis,
1988,481
Hope, cancer patients, 370-371
Hull, Clarke L, 256
Human performance, 451453
Humanistic approach, psychotherapy, 174
see also Psychodynamic and
humanistic approaches
Hyperemesis, pregnancy, 384
Hypersensitivity, PTSD, 430-431
Hypersuggestibility, 84-85
Hypertension, 343
pregnancy, 385
Hyperventilation, 416-417
Hypervigilance, 417-418
PTSD, 425, 430-431
Hypnoanalgesia
dentistry, 400
labour and delivery, 389-390
Hypnos, Swedish Society for Clinical and
Experimental Hypnosis, 495
Hypnosis
effectiveness in therapy, 473-476
introducing, 62-64
using the term, 97-98, 458
Hypnotic dreams and fantasies, 247-249
Hypnotic induction see Induction and
deepening
Hypnotic Induction Profile, 30-31
Hypnotic susceptibility see Susceptibility
Hypnotic susceptibility scales, 29-31
application, 32-33
Hypnotism Act, 1952,481
Hypochondria, 415
Hypothalamic-pituitarv-adrenal
system, 367
Ideomotor signalling, 217-225
age regression, 221, 232233
applications of, 220-222
Chevreuls's pendulum, 218
INDEX 515
linger movements, 218-220
overvaluing of responses, 222-223
reframing method, eating disorders, 449
working model for therapeutic utility,
222-225
Ideomotor suggestions, 19-20
Ideosensory suggestion, 18-14
Image habituation, PTSD, 426
Image of symptoms, psychosomatic
problems, 333
Imagery
cancer patients, 375-376
described by therapist, induction and
deepening, 73-75
haemostasis, cold and ice, 401
labour and delivery, 388-389
pain management, medical
conditions, 357
vividness and susceptibility, 34-35
Imaginal techniques
dental phobia, 406
desensitisation, phobias, 262
labour and delivery, 388-384
obsessive-compulsive disorder, 421
rehearsal, symptom control techniques.
334-335
Imagination and suggestibility, 48, 87-88
Immunological activity, suggestion and
imagery, 368
Indirect implications using the
negative, 111
Indirect suggestion, 84-90
concept of trance, indirect approach,
109-110
rationale, 108-109
styles of, 110-115
verdict on, 115-117
Induction and deepening
cancer patients, 374-375
children, 157-162
eclectic psychotherapy, 285
first approach (absorption), 67-81, 96
alerting patient, 76-77
complications, 78-80
definition, 67-68
first and later sessions, 80-81
group hypnosis, 81
methods, 7076
trance, signs of, 77-78
preliminaries, 69-70
pschosexual problems, 442443
psychosomatic problems, 334
PTSD, 427
second approach (suggestibility), 83-46
additional points, 95-96
definition, 85-86
methods, 91-95
preliminaries, 87-91
suggestion, maximising impact, 83-85
smoking cessation, 299
weight reduction, 310
see also Preliminaries to induction and
deepening
Infertility, 379-383
Informed consent, working with
children, 457-458
see also Hypnosis; using the term
Injuries
pain management, 361
PTSD patients, 423
Insomnia, 267, 315-320
assessment, 317-318
case example, 319-320
defining, 315-316
general advice, 316-317
psychological treatments, 318-320
International Journal of Clinical and
Experimental Hypnosis, 473,495
International Society of Hypnosis
(1SH),494
ethical guidelines, 496, 505-507
Interpretative biases, 412-413
physiological anxiety, 416-417
situational phobic anxiety, 418
Interrogative suggestibility, 36-37
Intrusive thoughts, memories and images,
PTSD, 425-430
Investigative hypnosis, 486
arguments against, 476477
arguments for, 477-178
criminal justice system, attitudes,
478-479
recommendations, 479
Irritable bowel syndrome, 341-342
'Is it possible?' protocol, 352-353
Itch-scratch-itch cycle, eczema, 464
James, unconscious mind, 203
Janet, Peirre, 12
Jigsaw puzzle visualization technique,
248-249
Journals, 445-196
The journey, metaphors and stories,
147-148
Kershaw, unconscious mind, 202
Labour and delivery, 385-392
research, 385-386
training for, 386-391
visualisation, 388-389
Lay practitioners, 484-485, 486, 494
scientific orthodoxy, need for, 491492
training courses, 497
516 INDEX
Leading questions, susceptibility to,
36-37, 477
legal and ethical issues, 458
hypnosis in dentistry, 398
stage hypnosis, Britain, 481
See also Ethical guidelines; Ethics
Life events, stressful, 368
Literal anecdotes, 143-144
Litigation
potential for, 33
PTSD, 432
therapy and compensation claims, 361,
422-423
Loss of control, dental phobia, 399
Lymphocytes, 367
Magic biscuits, ego-strengthening
routine, 167-168
Magic television, 158-159
Male partners, hypnosis for infertility, 381
The man, the boy and the donkey,
metaphors and stories, 149
The map
adaptive view of world, 274
metaphors and stories, 148
Massed practice, behaviour therapy, 268
Maze fantasy, 251-252
Medical conditions
hypnosis to treat, 288
weight reduction, 309
Medical and minor surgical procedures,
357, 359
children, 466-467
Meige's syndrome, 340
Melzac and Wall, Gate Control Theory, 357
Memories
belief of reliability, 477
eliciting and reliving, purpose of, 213-214
false see False memories
intrusive, PTSD, 424-425
therapeutic strategies, 425-430
reality and fantasy, 212
recovered, 209-214, 501-502
reification of, 212-213
resolving difficult, 236-242
Memory
clinical hypnosis and, 501-504
distortion, 432, 477, 478, 486
see also False memories
Mental state assessment
pain, 351
psychosomatic problems, 324-325,
325-326
Mesmer, Franz Anton, 4,6, 6-7
Mesmerism, 6-8
Metaphor and story technique, 143-154
bereavement, 150-153
cancer patients, 371
children, 158, 165-169,464-465
depression, 441
literal anecdotes, 143-144
metaphorical stories, 144-150
new metaphors, 169, 252
psychosexual problems, 443
psychosomatic problems, 336-337
rationale, 145-147
weight reduction, 147-148, 312
Migraine headaches, 343
Mind-body communication, 330, 332
childhood eczema, 464
Model Conditions, revised. Home Office
1996,482
Modelling, behaviour therapy, 261
Modern scientific era, 13-14
Mood and anxiety, assessment, 324-325,
325-326
Morning sickness, 384
Motivation, smoking cessation, 297,
298-299
Multiple personality disorder see
Dissociative identity disorder
Nail-biting, 266, 451
Natural killer cells, 367
Naturalistic approach to hypnosis, 109
Nausea
hand-on-abdomen method, 342
morning sickness, 384
Negative anchoring
children, 164-165
combining with positive, 139
posthypnotic suggestion, 141
tension control, 137-138
Negative reinforcement, 256-257
Negative self-hypnosis, depression, 437438
eliminating, 438-439
Neo-dissociation theory, 44-46
Neurophysiological theory, Wyke, 41-42
Neutral hypnosis, 101
Nightmares, techniques for, 430
Nocturnal enuresis, children, 461-464
Nominalisation and reification, unconscious
mind,204-205
Non-directive or client-centred
psychotherapy, 185-187
Non-state theories, hypnosis, 48-52
see also Absorption; Suggestion
Non-verbal communication, 223, 224
Obsessive-compulsive disorder, 272, 414,
419, 420-422
flooding, 263
response prevention, 264
INDEX 517
Obstetrics and gynaecology 379-394
gynaecological conditions, 392-343
infertility, 379-383
labour and delivery, 385-391
postnatal progress, 391-392
pregnancy, 383-385
Occam's razor, 8
Olfactory hallucinations. 21
Open-ended method, age regression, 232
Open-ended suggestions, indirect
suggestion, 111-112
Operant conditioning or learning,
256-257
Otani, unconscious mind, 202
Ouija board, ideomotor signalling, 225
Outcome, reasons for successful, 178-179
Overeatirtg and bingeing, 308
Overt vs covert methods, behaviour
therapy, 258
Pain, 14, 347-363
acute vs chronic, treatment issues,
361-362
applications, hypnotic procedures,
358-361
assessment and monitoring, progress,
351-353
attenuation of experience of, 26,27
cancer, 359, 375-376
children, 466-167
components of, 34S-349
dentistry, 399-400
effectiveness of hypnosis, 474-475
bidden observer, 4546
meaning in everyday life, 353
past experience of, 350
procedures, 353-358
theoretical considerations, 347351
use of word, 387,400
Panic disorder, 272, 414, 415
case example, 406407
negative reinforcement, 273
reality testing, 277
Paracelsus, 6
Paradoxes, indirect suggestion, 111
Paradoxical injunction, 135-136, 267-268
insomnia, 318
pain management, 354
psychosomatic problems, 333-334
Parcels fantasy, 250-251
Parts, use of see Ego-state therapy
Passive-alert methods, induction,
117-118
Patient
attitude to hypnosis, and suggestibility, 87
confidence building, and suggestibility,
87-90
losing touch, 78
Pavlov, Ivan, 41
Pavlovian, classical or respondent
conditioning, 257
Peer contact and support, importance of
maintaining, 498
Perls, Fredrich, 187
Permissiveness, indirect suggestion, 110
Personal map
metaphors and stories, 148
understanding the world, 274
Personality, stress and cancer, 365-366
Phase-oriented treatment approach,
traumatised patients, 503
Phobias, 414
children, 467-469
desensitisation, 262-263
flooding, 263
Phobic anxiety
irritable bowel syndrome, 337, 342
PTSD, 430-431
Phrenology, 10
Physical contact, 65-66
Physical injuries
pain management, 361
PTSD, 423
Physiological anxiety, treatment
approaches, 415-417
Physiological changes, 21-22
Placebo effect, 4, 37, 178, 324
Planning future activities, depression,
440-441
Plato, 365
Police, investigative hypnosis, attitude
towards, 477
Positive anchoring, 138, 376, 402, 405
combining with negative, 139
posthypnotic suggestion, 141-142
relaxation, bruxism, 401
Positive reinforcement, 256, 260
Post-traumatic stress disorder (PTSD), 272,
422-432
anger and hostility, 431
conclusions concerning hypnosis and, 432
depression, 431-432
general considerations, 422-424
hypervigilance, hypersensitivity and
avoidance, 430-431
intrusive memories and images, 424-425
sleep, 431
therapeutic strategies, 425430
Posthypnotic suggestion, 22, 122-126
as adjunctive technique, 126
children, 163
depression, 440
dreams, 246, 247
examples, 125
guidelines, 123-126
518 INDEX
Posthypnotic suggestion (continued)
psychosexual problems, 443
psychosomatic problems, 335
research findings, 123
self-control, 141-142
Postnatal progress, 391-392
Postural sway, ideomotor suggestions, 19
Power of healer, 4
Precautions, 97-99
Pregnancy, 383-385
labour and delivery, preparation for,
385-392
Preliminaries to induction and
deepening, 61-66
assessment see Assessment
cancer patients, 372-374
children, 156-157
eclectic psychotherapy, 285
ethical matters and precautions, 97-99
first approach, 69-70
psychosomatic problems, 330, 332-334
second approach, 87-91
Premature labour and miscarriage,
anticipated, 385
Primary suggestibility, 36
Professional and ethical guidelines,
494-498
Professional practice, issues in, 491-498
professional and legal requirements,
working with children, 457-458
Progression, age see Age progression
Progressive relaxation, 72-73
children, induction and deepening, 162
Protective bubble technique, traumatic
memories, 428
Psoriasis, 339
Psychoanalysis, 183-185
Psychodynamic and humanistic
approaches, 174, 183-191
Gestalt therapy, 187-189
non-directive or client-centred, 185-187
psychoanalysis, 183-185
transactional analysis, 189-191
Psychodynamic therapy
hypnotic procedures, 217-252
age progression see Age progression
age regression see Age regression
children and adolescents, 250-252
enhancing therapy, effectiveness
in,475
fantasy procedures, miscellaneous,
242-250
ideomotor signalling, 217-225
memories, resolving difficult, 236-242
sensory-focusing method, 225-229
psychosexual problems, 443-444
psychosomatic problems, 327
weight reduction, 312-313
Psychogenic dysphonia, 450-451
Psychoneuroimmunology, 366-369
Psychosexual problems, 441-445
hypnosis in, 442-444
Psychosomatic Medicine Research Clinic,
information for patients, 331
Psychosomatic problems, 323-344
additional techniques, 336-337
assessment, 324-326
case example, 337
duration of treatment and follow-up, 329
general and specific effects of treatment,
323-324
group treatment, 328
hypnosis, effectiveness in, 475
psychodynamic factors, secondary gain
and motivation, 327-328
safeguards, 328
specific problems, 337-344
successful treatment, indicators for, 329
techniques, overview, 329-337
Psychotherapy
common goals, 275
depression, 436-437
different approaches in, 173-175
eclectic approach see Eclectic
psychotherapy
effectiveness of, 474
Ericksonian approaches, 193-198
technique, definition of, 187
weight reduction, 308-309
working model, 175-181
see also Behaviour therapy; Cognitive
therapy; Cognitive-behavioural
therapy; Psychodynamic and
humanistic approaches;
Psychodynamic therapy
Psychotic illnesses, 290
Public-speaking anxiety, 475-476
Punishment
aversion therapy, 264
learning, 257
Puysegur, Marquis de Chastenet de, 8-9
Questionnaires, pain assessment, 351, 353
Questions, indirect suggestion, 113
Rape, psychosexual problems, 444
Rational emotive therapy, 278
Reactive inhibition, massed practice, 268
Reality testing, cognitive therapy, 277
Reciprocal inhibition, behaviour
therapy, 262-263
Recovered memories, 209-214, 501-502
Reframing, Ericksonian approaches,
196-197
INDEX 519
Regression see Age regression
Rehearsal in imagination
age progression see Age progression
behaviour therapy, 259
cancer patients, surgery or medical
treatment, 374, 375-376
cognitive, 285, 286
dental phobia, 406
eating disorders, 447
psychosomatic problems, symptomcontrol
methods, 334-335
self-control methods, 139- 141
Reinforcement, positive and negative,
256-257, 260
Reinterpretation, pain, 358
Relative analgesia, hypnosis as adjunct, 399
Relaxation
bruxism, 401
children, 156, 467
gagging, 402
and guided imagery, breast cancer,
368-369
ideosensory suggestion, 19
insomnia, 318-319
pain management, 354
premature labour, avoiding, 383
psychosexual problems, 443
Relaxation-induced anxiety and panic, 79
REM-non-REM cycle, 316
Repressed memories, 209-214
Repressors, trait anxiety, 413-414
Reprogramming, fantasies on theme of,
169
Research
direct and indirect suggestion, 115-117
hypnosis in labour, 385-386
posthypnotic suggestion, 123
see also Evidence, benefits and adverse
effects
Resolution phase, Ericksonian approaches.
195-196
Response prevention, behaviour
therapy, 264
obsessive-compulsive disorder, 420-421
Responsibility, inflated sense of, 421, 422
Risks, precautions and contraindications,
287-291,328,479
inadequately trained therapists, 483-485
labour and delivery, 390-391
stage hypnosis see Stage hypnosis
Rogerian psychotherapy, 185-187
Rogers, Carl, 185
Safe place method
induction and deepening, 75-76
PTSD, 427
Safety-seeking behaviour, 277
Schemas, 240, 279-280
anxiety, 420
PTSD, 424-425
School phobia, 467-468
Scientific orthodoxy, need for, 491-492
Scottish Society for the Practice of
Hypnosis in Speech Therapy, 449
Screen method
age regression, 234
traumatic memories, 427
Secondary gain, psychosomatic
problems, 327
Secondary suggestibility, 36
Self-control
behavioural techniques for, 135-142
bruxism, 401
children, 164-165
covert rehearsal, 139-141
posthypnotic suggestion, 141-142
smoking cessation. 302
weight reduction, 311
Self-deception, 53-54
Self-esteem, PTSD, 425
Self-hypnosis, 101-105
cancer patients, 372-376
children, 162-163
dentistry, 400, 405
finding time for, 103-104
insomnia, 318-319
labour and delivery. 387-389, 389
pregnancy, 383
procedures for, 101-102
psychosomatic problems, 335
purposes of, 104
self-control, 142
smoking cessation, 303
taped instructions, 104-105
teaching, 102-103
weight reduction, 311
Self-perception, PTSD, 425
Sensitisation, behaviour therapy, 264-266
Sensor-focusing method, 69, 91,
225-229
Setting, clinical hypnosis session, 61-62
Sexual abuse, 272, 444
'recovered memories', 209, 210
Sick role, psychosomatic problems, 327
Significant memories, anxiety, 420
Situational phobic anxiety, treatment
approaches, 417-418
Skills, human performance, 452
Sleep
deprivation, 316
PTSD, 431
questionnaire, 317-318
see also Insomnia
Sleep onset insomnia, 315
520 INDEX
Sleeping tablets. 317
Smoking cessation, 295-304
conclusions, 303-304
general considerations, 296-299
hypnotic procedures, 299-303
non-hypnotic techniques, 303
success rates, 476
see also Abstention
Social and cognitive theories,
hypnosis, 48-52
Social phobia, 414
Socially anxious individuals, 418
Societies of hypnosis, 473, 494-495
Society for Clinical and Experimental
Hypnosis, database, 473
Spanos, Nicholas, 51
Spanos technique, 88, 89
Spasmodic torticollis, 340
'Special place' method, 75-76
PTSD, 427
Special state or special-process
theories, 42-46,47
Spectators, audience and examiners,
adverse reactions to, 452-453
Speech and language therapy, hypnosis in,
449-451
Spiegels, affirmations, 302, 311, 447
Sports people, performance, 451-453
Stage hypnosis, 53, 63, 229, 480-483,
486-187
alleged adverse effects, 480-481
Stanford Clinical Scale for Adults, 30
Stanford Hypnotic Arm Levitation and
Induction Test, 30
Stanford Scales of Hypnotic Susceptibility,
29-30
Staring at coin or fingernail, 159-160
State anxiety, 412-413
Stimulus control, 267
insomnia, 318
weight reduction, 308
Stories and metaphors see Metaphor and
story technique
Strategic enactment, 51-52
Stressful life events, 368
Strong interpretation of trance see Altered
states of consciousness
Stuttering, 450
Subconscious mind, metaphor for
reprogramming habits, 166-167
see also Unconscious mind
Suggestibility, 12, 84-85
types of, 36-37
Suggestion, 5
authoritarian vs permissive, 107-108
complex, 22
definition, 16-17
demonstrating, 15-16,87-91
direct vs indirect, 108-117
indirect, 89-90, 110-117
induction and deepening, 85-86, 91-95
maximising impact, 83-85
and physiological functioning, 324, 401
response of subject, 17-18
therapeutic suggestions during hypnosis,
122
types of, 18-22
see also Posthypnotic suggestion
Suggestions
complex, 22
dentistry, 401,405
glove anaesthesia see Glove anaesthesia
nocturnal enuresis, 463
numbness and insensitivity, pain
management, 355-356
phobias, children, 468
Suicide risk, 290, 436
Susceptibility, 29-37
Abbe de Faria, work of, 9
and absorption, 25-26, 34
children. 155
correlates of, 33-36
measures, 29-31
applications of, 32,33, 326, 353
PTSD, 423-424
Sympathetic-adrenal-medullary system, 367
Symptom prescription see Paradoxical
injunction
Symptom substitution, psychosomatic
problems, 328
Symptom-control methods,
psychosomatic problems, 334-335
practice, 335-336
Symptoms, patient's imagery of, 333,373
Systematic desensitisation, behaviour
therapy, 262-263
Taking the plunge, metaphors and
stories, 150
Tape recording of session, 99
cancer patients, 372
working with children, 463
Taped instructions, self-hypnosis, 104-105
Telescoping trauma and too-late
comfort, 238-239
Tellegen Absorption Scale, 25
Temporomandibular joint dysfunction, 398,
403-404
Tension headaches, 221
Thematic Apperception Test, 244
Therapeutic relationship working with
children, 458-459
Thought-action fusion, obsessivecompulsive
disorder, 421
INDEX 521
Thought-stopping and decentring;, 266-267
Thumb-sucking, 451
Tickling, ideosensory suggestion, 19
Tics, 340-341
Tidying a desk, ego-strengthening
routine, 168-l69
Tidying a garden, ego-strengthening
routine, 168
lime distortion, 22, 26, 27
pain management, 354-355
Time out, behaviour therapy, 266
Tinnitus, 344
Tourette's syndrome, 341
Training
ethical and professional matters
concerning, 496-498
guide for persons seeking, 497
Trait anxiety, 413-414
Trance, 23-27
Ericksonian concept of, 109-110, 197
signs of, 77-78
'strong' interpretation, 24
'weak' interpretation of, 24-26
'Trance logic', 46, 229
Transactional analysis, 189-191
Transference, 13, 184
Trauma see Injuries
Traumatic memory, 501
Traumatised clients, standards of care,
502-504
Travel anxiety, following accident, 423
Ulceration, gastro-intestinal. 342-343
Ulcerative colitis, group therapy, 343
Unconscious mind
alternatives to, 205-208
assumptions concerning, 202-203
concept of, problems with, 203-205
resources, Ericksonian approaches.
194-195
statements from hypnosis literature.
201-202
Unresolved grief, 382, 383
Urinary incontinence, adults, 344
Urinary retention, functional. 267
Urticaria, 339
USA, criminal justice system, 478-479
Utilisation, Ericksonian approaches, 193
Ventilation of feelings, difficult
memories, 238
Verbal instructions, behaviour therapy,
258-259
Verbal and non-verbal communication,
223-224
Verbal triggers, children, induction and
deepening, 162
Vicarious learning, behaviour therapy,
261-262
Videotaping session, 99
Visual hallucinations, 21
Visualisation, labour and delivery,
388-389
Voice, tone of, 69, 95
Vulvodynia, 392-394
Warts, 338-339, 465-466
Watkins, John and Helen, 190
Watson. John B, 255
Waxman, David, 481
Weak interpretation of trance see
Absorption; Suggestibility
Weighing, weight reduction, 306-307
Weight loss, recommended, 305
Weight reduction, 304-315
assessment, 309-310
conclusions, 314-315
general considerations, 304306
hypnotic procedures, 310-314
non-hypnotic techniques, 306-309
Wintertime, metaphors and stories, 149
Wolberg's theatre visualisation
technique, 248
Working model, concept of, 55-56,
175-181
ethical implications, 180-181
gynaecological conditions, 392-394
implications for practice. 179-180
outcome, reasons for successful,
178-179
testing, 176-178
working model as scientific theory, 176
see also Anxiety: cognitive model for
Worrying, 419
worrying chair, 267
Writer's cramp, 340
Wyke, neurophysiological theory, 41-42
Yapko, unconscious mind, 202
The Yes set, indirect suggestion, 115
Young children, induction and
deepening, 158
FOURTH EDITION
HARTLAND'S
and Den Htaylp nosis
This book is an extensively revised edition of a highly successful and comprehensive
introductory manual for the use of clinical hypnosis in the treatment of medical and
psychological problems and disorders. Written with the interests and needs of the doctor or
dentist in mind, also psychologists, psychotherapists, and oilier health professionals, its
practical arid dear approach maintains the tradition of usefulness and high-quality
information established in previous editions of this book. After exploring the theoretical and
historical background to hypnosis, and key techniques and approaches, the book looks at
specific clinical situations and problems in which hypnosis may have an impact, and offers
specific practical management guidelines, including possible scripts.
Features
Highly practical ,and accessible in scope
and approach
Oilers clear guidelines on key hypnosis
techniques, plus safety considerations
Reviews all the main applications of
hypnosis in medicine, dentistry, psychiatry
and psychology referring to evidence from
clinical research
Gives sample scripts which offer the
leader a 'springboard' to clinical practice
Explores ethical issues in clinical practice.
possible adverse effects (including the
'recovered memory' controversy), issues
concerning lay practitioners and stage
hypnosis with reference to the current
literature
Overviews the psychodynamic,
behavioural, cognitive and humanistic
approaches to psychotherapy for the
unfamiliar reader
Challenges traditional conceptions of
hypnosis as a therapeutic medium and
offers an eclectic framework based on
mainstream cognitive-behavioural
approaches
About the authors
Dr Michael Heap, Chartered Clinical Psychologist, Wathwood Hospital, Rotherham. UK
Dr Kottiyattil k. Aravind. GP, Rotherham. UK
From the foreword by Peter B. Bloom
"There is much in this volume for every clinician...a definitive, comprehensive text ...
i congratulate the authors on an extraordinary achievement."
CHURCHILL
LIVINGSTONE
A Harcourt Health Sciences Company
Harcourt
Health Sciences
Visit our website for
additional outstanding products
www.harcourt-international.com
See inside for more information